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New Patient Medical History

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.

(include city + postal code)

(Please bring this information with you to the office)

If yes, fill out reason below

If yes, please list below

If yes, please enter reason below

If yes, please list below

If yes, please enter how many per day below.

If yes, please enter drinks per day / drinks per week below.

If yes, please enter the medical condition below.

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