To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.
If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient.
If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.
DENTAL HISTORY & SYMPTOMS
MEDICATIONS & OTHER PRODUCTS/SUBSTANCES
Please check in the box ONLY if this applies to you.
WOMEN ONLY: Are you:
Please check your answers to the following questions.
Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycin- sulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix).
MEDICAL HISTORY SPECIFIC Please check your answers to the following questions.
Do you have, or have you been diagnosed with, any of the following conditions?
Breathing (Respiratory) Health
Blood (Circulatory) Health
Brain (Neurological)/Mental Health
Please check your answers to the following questions
In the past 30 days, have you: