Medical and Dental History

  • List Any Medications Or Substances To Which You Are Allergic

  • List Your Current Medications

  • Medical History

  • Please specify Treatment and Approximate Date
  • I authorize the release of a full report of examination findings, diagnosis, treatment program, etc. to any referring or treating dentist or physician. I additionally release any necessary medical information to insurance companies for legal documentation. I understand that I am fully responsible for all fees for treatment at time of service and regardless of insurance coverage.