Dental Information


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Patient Information

Responsible Party / Billing Information

Insurance Information

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Medical History

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Aspirin Codeine Valium
Iodine Sulfa Drugs Tetracycline
Penicillin Erythromycin Novocaine
Xylocaine Nitrous Oxide Latex
 
Arthritis or Gout Artificial Joint Asthma Allergies Bleeding Problem or Anemia Blood disease Blood Transfusion Bruise Easily Cancer Cold Sores Congenital Heart Problems Currently Pregnant Diabetes Dizziness or Fainting Drug/Alcohol Addiction Eating Disorder
Emphysema Epilepsy or Seizures Fever Blisters Frequent Thirst Frequent Urination Glaucoma Heart Attack or Stroke Heart Murmur Heart Trouble Heart Valve or Pacemaker Hepatitis (A) Hepatitis (B) Hepatitis (C) Herpes Low Blood Pressure High Blood Pressure
HIV-AIDS-ARC Hypoglycemia Jaw Joint Pain Kidney or Liver Disease Lung Disease Psychiatric Care Radiation/Chemotherapy Rheumatic Fever Sinus Problems Thyroid Problems Tuberculosis Tumor or Growth Ulcers or G.I. Problems Use Tobacco X-ray/Chemotherapy
 
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Recreational use combined with local anesthesia may cause a life-threatening emergency.

Dental History

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Nearest Relative