My problem or reason for seeking treatment is:
If not, please describe
If yes, do you use a wheelchair?
If yes, what is the condition being treated:
If yes, please describe:
If yes, please describe your experience:
If yes, what is the duration:
If yes, list them here:
Also check any of the following if you are taking them:
a. Are you pregnant or trying to become pregnant?
b. Are you taking birth control pills or Hormones?
Permission is hereby granted to the staff of this office for such procedures and anesthesia as may be necessary for the care of the undersigned patient. Permission is granted to release my medical-surgical records to my primary Dentist or Physician. Permission is also granted to take x-rays, images, or photographs that could be used for diagnostic or educational purposes. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set fourth above have been answered to my satisfaction. I will not hold my dentist responsible for any errors or omissions that I may have made in the completion of this form.
Signature of patient or legal guardian X
Relationship to patient
Doctor's Comments
