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ADULT MEDICAL HISTORY FORMS
BRIARCLIFF SMILE DESIGN

It is important that you schedule your appointment first and then fill up the medical history forms part 1 and part 2 both.

ADULT MEDICAL HISTORY FORM

Part-1

Please fill out the form completely.

The better we communicate, the better we can care for you!

You current Physical Health condition is
Have you ever taken Phen-Fen? (Also known as Redux or Pondimin)
For WOMEN- Are you taking birth control pills?

Thanks for submitting!

ACKNOWLEDGEMENT
I understand that the information that I have given today in the strictest confidence and it is my responsibility to inform Briarcliff Smile Design dental office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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INSURANCE INFORMATION

If Briarcliff Smile Design Dental office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my Insurance does not cover.

NOTE:

Payment is due in full at the time of treatment unless prior arrangements have been approved.

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Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. Please read about HIPPA COMPLIANCE HERE.

ADULT MEDICAL HISTORY FORM

Part-2

Do you require Antibiotics before Dental Treatment?
Are you currently in pain?
Do your Gums ever bleed?
Did you ever had any serious dental injury?
Do you currently have or experienced pain in Jaw-Joint(TMJ/TMD)?
Your current dental health is
What do you like the most?
Type of Bristles?
Do you Smoke or use Tobacco in any form?
Are you Allergic to any of the following?(choose multiple if needed)
Have you ever had any of the following diseases or medical conditions?

Thanks for submitting!

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