Patient Health Form

WELCOME! Thank you for selecting Blue Periodontics.

To help us meet all your healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us and we will be happy to help.

Patient Information (Confidential)

 

Emergency Contact

 

Method of Payment

 

Patient Medical History

  • 6. Are you allergic to or have you had any reactions to the following:

  • 8. Women Only

  • 9. Do you have - or have you had - any of these conditions?

 

Patient Dental History

  • 6. Have you experienced any of the following problems in your jaw?

  • 7. Please answer the following questions.

 

Esthetic Evaluation

 

Authorization and Release

  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the Dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I agree to be responsible for payment of all services rendered on my behalf or my dependents at the time of treatment rendered.


    Signature: ___________________________________________________ Date:______________
    (The signature of Patient (or Parent/Guardian if Minor) above will be physically signed when at dental office.)

  • By clicking on the "Submit" button, you acknowledge that the information you provided in the form above is correct and valid to the best of your knowledge. The answers you provided are both accurate and true. You understand that providing incorrect information can be dangerous to your health.
 

Verification