For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
Do you have any of the following?
Are you allergic or have you ever had a reaction to:
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquires set forth above the have been answered to my satisfaction. I will not hold my dentist, or any other member of his or her staff, responsible for any errors or omissions that I may have made in the completion of this form.