Medical Sedation History

Medical Sedation History Form

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain anything that you do not understand. Please fill in the entire form.

Personal Information
Name*
Prefix First Middle Last
Sex*
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City Province Postal Code
Cell Phone*
Home Phone
Work Phone
Email*
Emegency Contact
Name*
First Last
Relationship to you*
Phone*
(If Applicable) Parent or legally authorized representative
Name
First Last
Family Doctor
Name*
Phone*
(If Applicable) Medical Specialist
Name
Phone

Women Only
Are you pregnant or suspect you might be?*
- Yes
- No
What is your anticipated delivery date?*
Date Format: MM slash DD slash YYYY
Are you breast feeding?*
- Yes
- No
Are you taking any birth control pills?*
- Yes
- No
Which brand?
NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE
I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary to obtain information that is required for my dental care.
Signature
- Patient
- Parent
- Legally Authorized Representative
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Medical Sedation History Form

Step 1 of 4

Personal Information

Emegency Contact

(If Applicable) Parent or legally authorized representative

Family Doctor

(If Applicable) Medical Specialist

Medical Questionnaire

Women Only

NOTE: IT IS IMPORTANT THAT ANY CHANGES IN YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE