Medical History Update

Patient Name*

Emergency Contact (name & phone number)*

Although dental personnel primarily treat the area in and around the 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 receive. We thank you for your cooperation in answering the following questions.

Your physician’s name and phone number*

Medical specialist’s name and phone number (if applied)

Are you taking any medication, non-prescription drugs, or herbal supplements of any kind?

If yes, please list below:

MEDICATION

WHAT FOR?

DOSE

FREQUENCY

Pharmacy name and location

Have you ever been hospitalized or had a major operation?

Yes

If yes, please explain

Women: Are you pregnant?

Yes

Due Date

Taking Contraceptives?

Yes

Are you allergic to any of the following?

Aspirin

Penicillin

Sulfa Drugs

Codeine

Local Anesthetic

Acrylic

Metal

Latex

Other?

Other? Please explain:

Do you have a history of substance misuse (current or past)?

Yes

What type?

Alcohol

Marijuana

Methamphetamine

Cocaine

Heroin

Other:

Last time of use

Duration of use

Do you have, or have you ever had, any of the following? Check all that apply

Have you ever had any conditions or diseases not listed above?

Do you have any concerns about your teeth or your smile?

Cancellation Policy:
When you book an appointment with us, we reserve that time specifically for you with the dentist and/or hygienist. As such, we required two business days (48hours) notice, in the even an appointment must be changed or cancelled. This allows other patients awaiting treatment to be rescheduled in the slot initially reserved for you. Short notice cancellation (i.e. less than 48 hours’ notice) and no show appointments will be subject to a broken appointment fee of $50-$100. Life happens and we understand that sometimes you just can’t make it for a valid reason, in this case your card will not be charged for a first offence if it is for a valid reason.

I consent to the electronic submission of all dental claims and predeterminations to my third party insurance provider(s) and authorize the release of all necessary information for this purpose.

I consent to the release of my personal and dental health information to other healthcare providers, specialists, or facilities as necessary for the purpose of referrals, consultations, and continuity of care.

Office Policy statement: If a patient, under the judgement of the treating dentist, is suspected to be under the influence of a controlled substance, patient will be rescheduled and return when sober for care.

To the best of my knowledge the above information has been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any medical changes.

Signature of Patient/ Parent/ Guardian*

Name of Parent / Guardian (if applicable)

Signature of Dental Provider

Date*

Photograph consent:
Consent: I authorize Dr. Sara Syed & Associates to take dental photographs for diagnostic, treatment, educational, and promotional purposes.
I understand that:

My photographs may be used in medical records, educational materials, and promotional content.
No identifying information will be used without my explicit consent.
I can withdraw my consent at any time with written notice.

Authorization (to sign if agreed):

Patient’s Signature

Medical and Dental History PDF

PASSIONATE ABOUT YOUR TEETH

EMERGENCY DENTAL CARE