I understand the information that I have given today is correct to the best of my knowledge. I also understand that this information is con dential and it is my responsibility to inform this office of any changes in my medical status.
I am directly responsible for payment to this of ce for professional services rendered to me. Your electronic signature also acknowledges receipt of notice of Annapolis Prosthodontic Associates’ Privacy Practices. Typing your name in the box below ackknowedges receipt of this notice. Enter your name

Physician's name:

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Your Current Health

Currently under doctor's care for medical problems?

If yes for what reason(s)?

Have you been hospitalized in the past 5 years?

Please list any medications or herbals you are currently taking:

Are you or have you ever taken bisphosphonates (ie:Actonel, Boniva, Fosamax, etc.) for osteoporosis or cancer treatment, either oral or IV?:

If Yes, name of medication

What is the purpose of your visit today?

Are you currently experiencing a dental problem?

Do you smoke tobacco products in any form?:

Women - Are you pregnant?

If yes what week#?

Do you require antibiotics before dental treatment?

If Yes, what condition?

List Allergies (penicillin, codeine, Novocain, jewelry, latex, etc.):

Do you have or have you had any of the following
medical conditions?

Enter date

Date of last Physician's visit: