As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain,. Your answers are for our records only and will be kept confidentiaal subject to applicable laws. Please not that you will be asked some questions about your responses to this questionnaire and there may be additional questions cencerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
If you are completing this form for another person, what is your relationship to that person?
Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays
What is the reason for your dental visit today?
How do you feel about your smile?