3029 Avenue V, Brooklyn NY 11229
1985 Ocean Avenue, Suite 1-D, Brooklyn, NY 11230-6815
OR FILL OUT THIS FORM ONLINE
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Do you need to pre-medicate?
Are you Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Are you allergic to any of the following?
Have you ever had any serious illness not listed above?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN