Check only the ones that apply
List all medications and / or supplements you are taking
*** All Payments and / or co-payments are due at the time of service ***
* Any x-rays or diagnostic models taken are the property of this office
patients pay for the diagnostic services, not the materials
To the best of my knowledge, the questions on this form have been accurately answered. I undertand 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.