Referring Dentist Infomation
Patient Information
Patient Information
Dental History
Dental Concerns
Medical History
If you have health conditions involving any part of your body, this may have a relationship with your dental health and could influence the type of dental care and the way we administer your sedation. You are helping us provide you with the best possible care by completing this questionnaire as carefully as possible.
Have you ever had sedation in a dental office?
Medical Conditions
Past and Current Conditions (check all that apply to you, now or in the past)
Cardiovascular
Pulmonary
Endocrine
Other Conditions
Medical History Continued
Are you allergic, or have you had any unusual reaction to any of the following?
Prostheses

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