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If you answer yes to any of the three items above, please stop and return this form to the receptionist.
If Yes
If No
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment
I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
Patients Signature
Date
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