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Medical History
Consent for Dental Treatment
Financial Agreement
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MEDICAL HISTORY
Physician
Office Phone
Date of last exam
Are you under any medical treatment now?
Yes
No
Hospitalized for surgery/illness (last 5 yrs)?
Yes
No
Taking any medication?
Yes
No
If yes, plese list you medication(s)
Do you use tobacco?
Yes
No
Have you ever taken phen phen?
Yes
No
Do you use controlled substances?
Yes
No
Are you taking any medication for osteoporosis?
Yes
No
Do you have or had any of the following (please select yes or no)
High Blood Pressure
Yes
No
Low Blood Pressure
Yes
No
Chest Pain
Yes
No
Heart Attack
Yes
No
Cardiac Pacemaker
Yes
No
Heart Disease
Yes
No
Rheumatic Fever
Yes
No
Heart Murmur
Yes
No
Stroke
Yes
No
Osteoporosis
Yes
No
Angina
Yes
No
Mitral Valve Prolapse
Yes
No
Fainting / Seizures
Yes
No
Frequently Tired
Yes
No
Tuberculosis
Yes
No
Asthma
Yes
No
Anemia
Yes
No
Radiation Therapy
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Glaucoma
Yes
No
Epilepsy / Convulsions
Yes
No
Cancer
Yes
No
Recent Weight Loss
Yes
No
Leukemia
Yes
No
Arthritis
Yes
No
Respiratory Problems
Yes
No
Diabetes
Yes
No
Joint Replacement / Implant
Yes
No
Swollen Ankles
Yes
No
Kidney Disease
Yes
No
Hepatitis / Jaundice
Yes
No
Liver Disease
Yes
No
AIDS or HIV Infection
Yes
No
Stomach Troubles / Ulcer
Yes
No
Hay Fever / Allergies
Yes
No
Thyroid Problem
Yes
No
Sexually Transmitted Disease
Yes
No
Other
Are you allergic to or have you had any reactions to the following?
Local Anesthetics (e.g. Novocain)
Yes
No
Aspirin
Yes
No
Sedatives
Yes
No
Penicillin or other antibiotics
Yes
No
Any Metals
Yes
No
Latex Rubber / Powder
Yes
No
Sulfa Drugs
Yes
No
Iodine
Yes
No
Other
Women ONLY
Are you pregnant or think you may be pregnant?
Yes
No
Are you Nursing?
Yes
No
Are you taking any oral contraceptives?
Yes
No
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information including diagnosis and the records to any treatment or examination rendered to my child or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less then the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I consent to the dental x-rays, diagnostic procedures and treatment by the dentist necessary for proper dental care.
Signature of Patient / Parent / Guardian
Date
Dentist's Signature
Date
FOR FUTURE VISITS/APPOINTMENTS ONLY- RECALL REVIEW UPDATE & COMMENTS
Any change(s) in health history or Medical condition? If Yes, Please explain
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