New Patient Information

General Information
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

Dental Information
For the following questions, please check your responses to the following questions. (Check DK if you Don't Know the answer to the question)
Medical Information
For the following questions, please check your responses to the following questions. (Check DK if you Don't Know the answer to the question)

Allergies


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

Congenital heart disease (CHD)


Active Tuberculosis

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question). Note: If you answer yes to 4 of the listed questions. Please do not continue this form and call Bluegrass Dentistry directly to setup an appointment.


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.