Lakeshore Practic Dental Health Form - Holland Family Dentistry

Last Name

First Name

Middle Name

Address

City

State

Zip Code

Phone Number

E-Mail

SSN

Date of Birth

Emergency Contact

Relationship

Phone Number

Dental Information

For the following questions, please select your responses to the following questions

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems

Allergies

Are you allergic to or have you had a reaction to: (To all yes responses, specify type of reaction)

Please select your response to indicate if you have of have not had any of the following diseases or problems.

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

Name of physician or dentist making recommendation:

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No

Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful
health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries
set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action
they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian:

Date:

M	8am - 5pm
T	8am - 5pm
W	8am - 5pm
T	8am - 4pm
F	By Appointment Only
S	Closed
S	Closed

Health History Form

Dental Information

Medical Information

Allergies