Hands on Dental

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Medical History

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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury ?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet ?
Do you use tobacco ?
Do you use controlled substances?
Women: Are you Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Nursing?
Are you allergic to any of the following ?
  • Ameritas Life
  • Aetna Life Ins. Co.
  • Argus Dental & Vision Plan By AFCAC Barefit Solution
  • Careington Dental
  • Connection Dental Network
  • DentaQuest
  • DenteMax
  • Dentegra Dental
  • Delta Dental Ins. Co.
  • Florida Blue
  • Florida Combined Life
  • Florida Medicaid
  • GEHA
  • Guardian Dental Ins.
  • Humana Health Plan Of Florida
  • Lincoln Dental
  • Liberty Dental Plan
  • MCNA Dental
  • Medicare Florida
  • Met Life Dental
  • Premiere Dental Group
  • Principal Dental Ins.
  • United Concordia Dental
  • United Healthcare Ins.
  • Diverse Care – Sun Health and Dental Plan

Patient Registration

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Name:
Patient Is:

Responsible Party (if someone other than the patient)

Name
Address

Be Young Everyday With Our HandsOn-SkinCare Line

Be Young Everyday With Our HandsOn-SkinCare Line

Office Location - Fort Lauderdale