For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential. The information you provide on this form is essential and related to the proper dental treatment you receive. Please note that during your visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
Current State of Health
I certify that I have read and understood the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Please complete the enclosed medication list on last page and then sign below: