Linda Johnson DDS - Patient Forms

Although dental personnel primarily treat the area in and around your 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 will receive. Thank you for answering the following questions.

Patient, Parent or Guardian

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient`s) health. It is my responsibility to inform the dental office of any changes in medical status.

Name

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I consent to use Electronic Records and Signatures (Read Electronic Record and Signature Disclosure)

Relationship to patient

Name

Form: Eaglesoft Medical History

Patient Information

Women: Are you...

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Please choose YES or NO for all questions below.

Comments:

Patient, Parent or Guardian

Sign Form