Medical History Patient Details

Medical History Contact Information

Medical History Dental History

Please select all that apply

  •  Bad Breath
  •  Bleeding Gums
  •  Blisters on Lips or Mouth
  •  Finger Nail Biting
  •  Grinding Teeth
  •  Lip or Cheek Biting
  •  Loose Teeth or Broken Filings
  •  Orthodontic Treatment
  •  Pain Around Ear
  •  Periodontal Treatment
  •  Sensitivity to Cold
  •  Sensitivity to Heat
  •  Sensitivity to Sweets
  •  Sensitivity When Biting
  •  Frequent Headaches
  •  Jaw,Head or Neck Injuries
  •  Jaw Difficulty: Clicking and/or Pain
  •  Tooth Pain

Medical History Medical History

  •  Yes
  •  No
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  •  No
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  •  No
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  •  No
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  •  No
  •  Yes
  •  No

7. Have you had any allergic reactions to the following:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No
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  •  No
  •  Yes
  •  No

8. (Women Only) Are You:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

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  •  Yes
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Medical History Assignment and Release

I hereby authorize payment directly to

for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

(Please click below to draw/upload sign)
(Your IP Address :IP:3.237.67.179 )

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