• Health History

  • DAVIS & ROBERTSON D.M.D P.S.C.

    Welcome! So that we may provide you with the best possible care please complete this medical dental history form. All information is completely confidential.
  • DENTAL HISTORY

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  • Are any of your teeth sensitive to:

  • Do you:

  • Have you ever had:

  • Have you experienced:

  • Health History

  • For Women Only

  • I UNDERSTAND ALL INFORMATION IS NECESSARY TO PROVIDE ME WITH DENTAL CARE IN A SAFE AND EFFICIENT MANNER, I HAVE ANSWERED ALL QUESTIONS TO THE BEST OF MY KNOWLEDGE. SHOULD FURTHER INFORMATION BE NEEDED, YOU HAVE MY PERMISSION TO ASK THE RESPECTIVE HEALTH CARE PROVIDER OR AGENCY, WHO MAY RELEASE INFORMATION TO YOU. I WILL NOTIFY THE DOCTOR OF ANY CHANGE IN MY HEALTH OR MEDICATION.

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