Medical History Form
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You just completed the Medical History Form, we hope to get a hold of you soon!

Patient Information

Fields marked with an asterisk (*) are required.

General Information

How did you hear about our office?

Dental Insurance Information

If you have secondary insurance, Click Here and please fill out the information below.

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following which apply to you, and add any relevant comments.

Are you allergic to the following?

Please check any of the following that you have had or currently have

Dental History

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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  • Two Regis Court Dental boys in matching outfits
  • Husband and wife with their five children and beautiful smiles
  • Regis Court Dental family with three children

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We have seen great efforts over the years we have used Regis Court Dental Associates to keep our teeth healthy and have never been disappointed in our choice.

- Bill B.

Sedation Density See the Before & After