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Medical and Dental History- Innovation Drive Dental

Please take a moment to let us know about your medical and dental history so we may serve you more effectively.

Please check any of the following that may apply to you:

Do you floss?

How many time a day do you brush?

Any other health issues?
Do you have any allergies to any medications NOT listed above?
Are you currently under the care of a physician?

Family Physician Information:

Are you currently taking any prescription medications:
If so, please list:

Have you ever had complications following medical treatment?     Dental Treatment?  

On a scale of 1-10, how important is your dental health?

(1=not important; 10=very important)
Do you grind your teeth
(either consciously or during sleep)?

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I understand that I am financially responsible for services rendered to me or to my dependents that are not fully covered by my insurance (if applicable) and I may be billed for this remaining balance. I agree to pay all uninsured services or insurance differences at the time services are performed, unless other arrangements are made.

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