Medical Insurance Information (Please be prepared to present your card(s) and ID)
Indicate any of the following conditions you may have experienced (Please Select Y or N for EACH item)
Other Significant Health Concern:
List all current Prescription Medications and the reason you are taking them
I believe the information provided above to be complete and accurate. I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician, and I authorize the release of any medical information to insurance companies for legal documentation necessary to process claims.
Use your mouse cursor or the tip of your finger to sign below