Please check every box on this form, even if the answer is “N/A” (not applicable). This information will be kept in the strictest confidence.
You also should know that changes in other parts of your body may affect the oral cavity and what dental treatment can be done, even if they seem unconnected. Cardiac (heart) problems, artificial joints and diabetes are just some examples.
I certify that the answers given are correct to the best of my knowledge.