Medical History

Please check any of the following that you have had, or currently have.

Women

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.

You understand that by submitting this consent form, you are giving your consent to use and disclosure of your protected health information to carry out treatment, payment, activities, and health care operations.

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.