Patient History Form

The following Patient History Form is provided for your convenience.  You can fill out and submit this information online in order to save time during your visit to our offices.

Patient History Form

The following Patient History Form is provided for your convenience.  You can fill out and submit this information online in order to expedite the check-in process when you arrive for your appointment to our offices.

Patient Information
Insurance Information
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Dental History
Are you allergic to or have you had any side effects from any of the following :
Penicillin
Aspirin
Local Anesthesia
Other Antibiotics
Codeine
Other Medications*
Do you have or have you had any of the following:
Heart Problems
High Blood Pressure
Heart Murmur
Bleeding Disorder
Arrhythmia
Stroke
Sinusitis
Chemotherapy
Tuberculosis
Kidney Disease
Low Blood Pressure
Rheumatic Fever
Mitral Valve Prolapse
Anemia
Seizure
Hepatitis
Asthma
Latex Allergy
Colitis
Arthritis
Joint Replacement
Immune Disorders
Blood Disease
Blood Transfusion
Thyroid Treatment
Radiation Therapy
Diabetes
Have you ever been told to take antibiotic premedication prior to a dental appointment?
For our Female Patients
Are you pregnant?
Are you nursing?
Do you use birth control pills?
Emergency Contact
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Thanks for submitting your Patient History Form