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

Please fill out the following patient history form in order to expedite the check-in process when you arrive for your appointment.
Patient Information
Insurance Information
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Medical History
Are you allergic to or have you had any side affects 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
Low Blood Pressure
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Arrhythmia
Stroke
Seizure
Sinusitis
Thyroid Treatment
Asthma
Tuberculosis
Kidney Disease
Colitis
Arthritis
Joint Replacement
Bleeding Disorders
Immune Disorders
Anemia
Blood Disease
Blood Transfusion
Hepatitis
Chemotherapy
Radiation Therapy
Latex Allergy
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

Thank you!