Patient Registration and Health History 

To help us know you better, please complete the following confidential information

Health History

4. Are you allergic or reacted adversely to any of the following medications?

Please answer all with yes or no

6. Select any of the following that you have had or have at present:

Please answer all with yes or no

Dental History

Permit for Operations

This is to certify that I understand and consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures.