The following information is required by East Village Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.
This information greatly helps us.
Are you interested in Dental Financing or Payment Plan?
Info of person responsible for payment of account (if different from above)
Do you, or have you had, any of the following:
List all medications, supplements, and or vitamins taken within the last two years
Please advise us in the future of any changes in your medical history or any medications you may be taking.
I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.