In order to provide you with optimum dental care we require a thorough medical and dental history, which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.
(if you are wearing a partial or complete artificial denture please complete the following)
I, the undersigned, certify that I have provided an accurate and complete personal dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my dental history. I understand that information provided from or to any other dental health care providers may be necessary, and I consent to the release of this information.