Patient Health History

Print this form now if you want to complete the form manually and bring it to your appointment.

You may also type in your answers and then print the form for your records at the bottom.

For Women Only

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically- compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

If you want to print the completed page for your records, you must do so BEFORE you send us the form.

Copyright 2015, Curtis Marketing Group, Inc. Do not use without written permission from Curtis Marketing Group, Inc.

CONTACT US

  • Curtis Group
  • 9402 November Dr
  • St. Joseph, MN 56374
  • Phone: 1-320-363-0210
  • Fax: 1-320-363-0218
  • Email: Email Curtis Group