Patient Registration and Medical History

Patient info

Medical History:

Have you ever had any of the following? (check all that apply)

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

0 + 7 = ?