Ver.170921

Choice Dental Browns Plains

CONFIDENTIAL MEDICAL HISTORY FORM

Dear valued patient,

Welcome to our practice. The following information is requested to enable us to give you our best attention. Each question is related to modern dental procedures and is strictly confidential.

Health fund name:

Please answer the following questions regarding medical conditions and Health history:

Please give details if you answer yes to the following

(details if YES)

Patient Declaration:

(please click the box below to sign your signature)