YuSmileDental.com | Consent Form

Patient Name

Your name is required.

Date of Birth

Date of Birth is required.

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?

Yes

If yes, please explain:

Have you ever been hospitalized or had a major operation?

Yes

If yes, please explain:

Have you ever had a serious head or neck injury?

Yes

If yes, please explain:

Are you taking any medications, pills, or drugs?

Yes

If yes, please explain:

Do you take, or have you taken, Phen-fen or Redux?

Yes

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?

Yes

Are you on a special diet?

Yes

Do you use tobacco?

Yes

Do you use controlled substances?

Yes

Women: Are you

Pregnant/Trying to get pregnant?

Taking oral contraceptives?

Nursing?

To the best of my knowledge, the questions asked 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

Your signature is required.

Date

Date required.

Medical History