The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation,
medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any
errors or omissions that I may have made in the completion of this form.
I have reviewed my Health History and confirm that it accurately states past and present conditions.