Patient Registration Form

Medical History

Please fill out this form and hit the Submit button at the bottom of the page.
It will be securely sent to our office.

Patient Name:

Birth Date:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Please check the "Yes" box below for all that apply You can uncheck it by clicking in the checkbox again.

Are you under a physcian's care now? Yes

- Please explain:

Have you ever been hospitalized or had a major operation? Yes

- Please explain:

Have you ever had a serious head or neck injury? Yes

- Please explain:

Are you taking medications, pills, or drugs? Yes

- Please explain:

Do you take, or have taken, Phen-Fen or Redux Yes

Are you on a special diet? Yes

Do you use tobacco? Yes

Do you use controlled substances? Yes

Woman: Are You

Pregnent/Trying to get pregnant? Yes

Taking oral contraceptives? Yes

Nursing? Yes

Are you allergic to any of the following? Please check any that apply

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Local Anesthetics

Other

Please explain:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Print Name

SIGNATURE OF PATIENT, PARENT, or GUARDIAN

DATE

Submit this form automatically to Smith Valley Smiles