We need this information to ensure your safety and health and the best possible dental care for you. All information is kept confidential among only our staff, your emergency contacts, and, if necessary, your doctor. Please fill in the fields below and click "submit". Your Submission of this form By submitting this form you agree that you:
have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information
have had the opportunity to ask questions and receive answers about your medical-dental history
authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care
understand that consultation with your medical doctor may be required, and you consent to your physician being contacted if necessary
understand that responsibility for payment for the dental services provided for you or your dependents is yours, and you will assume responsibility for fees associated with these services.