If you are completing this form for another person, what is your name and relationship to that person?
If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.
DENTAL HISTORY & SYMPTONS
MEDICATIONS & OTHER PRODUCTS/SUBSTANCES
Please mark if you are allergic to or have you had an allergic reaction to:
MEDICAL & SURGICAL HISTORY
Please mark your answers to the following questions.
MEDICAL HISTORY SPECIFIC
Please mark you answers to the following questions if you have, or have you been diagnosed with, any of the following conditions:
Hearth (Cardiac) Health
Breathing (Respiratory) Health
Blood (Circulatory) Health
Brain (Neurological)/Mental Health
Eye (Vision) Health
Do you have any disease, condition, or problem that’s not listed here?
Please mark your answers to the following questions if in the past 30 days, have you:
AUTHORIZATION AND RELEASE
I have answered the above questions completely, accurately and to the best of my ability.