Medical History

Yes
No
Yes
No
Aspirin
Codeine
Iodine
Latex
Local Anesthetic
Penicillin
Sulfa
Other

Do you have any of these diseases or conditions?

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Type 1
Type 2
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

NEW PATIENTS ONLY:

DENTAL TREATMENT CONSENT

I have provided an up-to-date medical history as listed above, and I will inform Smiles Inc of any changes to my medical history at subsequent visits. I consent to x-rays, anesthetic, dental/surgical treatment as prescribed by a dental professional.