Medical Sedation History

Women Only
Are you pregnant or suspect you might be?*
- Yes
- No
What is your anticipated delivery date?*
DD slash MM 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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Personal Information