Your cooperation in completing this questionnaire is essential to provide
you with safe and appropriate dental care. All information is strictly
confidential. A member of our team will be able to assist you with the
completion of this form if necessary.
CAREGIVER/GUARDIAN INFORMATION (IF APPLICABLE):
Office Policy Your appointment time will be reserved for you. If you are
unable to keep the appointment, we will require 48 hour’s notice,
otherwise it may be necessary to charge for the time lost.
INSURANCE INFORMATION (IF THE PATIENT HAS A DENTAL PLAN, PLEASE COMPLETE
MEDICAL HISTORY (PLEASE SELECT YES OR NO TO EACH QUESTION)
Do you have or have you ever had a replacement or a repair of a heart
valve, an infection of the heart
(i.e. infective endocarditis), a heart condition from birth (i.e. congenital
heart disease) or a heart transplant?
Do you have any conditions or have undergone therapies that could affect
your immune system? (Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)