Ocotillo Dental Care

Jeffrey S. Garelick, DDS

DENTAL HISTORY

Check the appropriate box if you have ever had or currently have the following:

HEALTH HISTORY

Check the appropriate box if you have ever had or currently have the following:

MEDICATIONS:

ALLERGIES:

CONSENT:

The information on this questionnaire is accurate to the best of my knowledge. I understand this information will be used by the dentist to help determine appropriate dental treatment. If there is any change in medical status, I will inform the dentist. The undersigned hereby authorizes the doctor or doctor’s staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs. Refusal of diagnostic aids at any time will release the doctor of responsibility for early diagnosis. I also authorize the doctor to perform any and all forms of treatment, medication, and therapy that may be indicated.