Name

Full name

Email

1. Are you currently under a physician’s care (for reasons other than routine/preventative care)

If yes, please explain

Physician’s name

Physician’s Number

2. Have you had any serious illnesses or operations?

If yes, please explain

3. Have you been in an accident resulting in a head or neck injury?

If yes, please explain

4. WOMEN: (Men can skip this point)

Are you pregnant?

Are you nursing?

Are you taking birth control?

5. Do you require any antibiotic premedication for your dental appointments?

If yes, please select from the list below.

6. Do you take any anti-clotting medication such a Coumadin, Warfarin or Aspirin?

7. Check if you have or had have any of the following:

Medications and supplements

Allergies