Dentists provide care to the region in and around your mouth. If you have health conditions involving other parts of your body, this may have a relationship with your dental health and could influence the type of care you will receive. You are helping your dentist provide you with the best possible care by informing him of these conditions.
Please check the appropriate response
Do you have, or have you ever had:
Are you allergic, or have you had any unusual reaction to any of the following?
Do you have, or have you ever had, any of the following?
PAST AND CURRENT CONDITIONS
Have you previously had dental treatments such as:
I, the undersigned, hereby declare that I have read, understood and answered the above medical/dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up as well as my registration on the recall list of the attending dentist(s). I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.