Patient Form


	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.


	Are you under a physician’s care now? Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? Are you on a special diet? Do you use tobacco? Do you use controlled substances?


	Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No


		If yes, please explain: _______________________ If yes, please explain: _______________________ If yes, please explain: _______________________ If yes, please explain: ________________________ _________________________________________ _________________________________________
	Women: Are you Pregnant/Trying to get pregnant? Nursing Taking oral contraceptives?


	Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other If yes, please explain: ___________________________________________________________


	Do you have, or have you had, any of the following?


	Have you ever had any serious illness not listed above? Yes No If yes, please explain: _______________________________


	Comments:________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand 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.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN ____________________________________ DATE _________

[Peppes Dental] [Dr. Peppes] [Dr. Lenz] [Staff] [Location] [Hours/Finance] [Cosmetic Dentistry] [Bleaching] [Bonding] [Enamel Shaping] [Tooth-Colored Fillings] [Veneers] [Dentistry Today] [CEREC] [Invisalign] [Implants] [Sealants] [Air Abrasion] [FYI-Oral Cancer] [Special of the Month] [We're Here For You] [New Patient Info] [New Patient Form 1] [Patient Form - 2] [Patient Form - 3] [Photo Gallery 1] [Photo Gallery 2]