Have you been under the care of a medical doctor during the past two years? Yes No
Have you taken any medication or drugs during the past two years? Yes No
Are you taking any medication, drugs or pills now? Yes No
Are you subject to prolonged bleeding? Yes No
Have you now, or have you in the past, taken bisphosphonates (Bonvia, Fosamax, Zometa)? Yes No
Do you have or have you had any disease, condition, or problem not listed? Yes No
Taking birth control pills? Yes No
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to use and disclosure of my protected health information to carry out treatment, payment, activities and health care operations.
