Confidential Patient Information – II

    Patient Name:

    Initial Date:




    Health Information

    Personal Physician Name:

    Personal Physician Address:

         1. Have you been hospitalized within the past 2 years? For what?

         2. Are you currently being treated by a physician? For what?

         3. Are you currently taking any medicines or drugs? What?

         4. Have you ever received counseling for excessive use of alcohol and/or prescription drugs?

         5. Are you allergic to any drugs? What?

         6. Have you ever had a skin rash or other reaction to metal jewellery? To What?

         7. Are you allergic to any metals? What?

         8. Do you bleed excessively upon injury?

         9. Are you pregnant?

         10. Have you ever been involved with dental/medical legal activity?

    Check The Box Of Any of The Following Conditions That You Have Had Or Now Have

    Person to Be Contacted in Case of Emergency (Other Than Relative)







    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

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    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.