Patient Health History (Alerts Corrected)
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.
Does your child have any of the following conditions? Mark all that apply.
Physician Information
Pharmacy Information
Previous Dental History
My child's attitude toward dentistry is:
What is the purpose of your chlid's dental visit today?
I understand that the information that I have given is correct to the best of my knowledge and that it will be held in the strictest confidence. It is also my responsibility to inform this office of any changes in my child's medical status. I authorize Dr. Jan Carlson and any members of her team to perform the necessary dental services my child may need.