Do you have any disease, problem or condition not listed above? Please explain___________________________________ ____________________________________________________________________________________________________
Are you required, due to health, to restrict your work or activity in any way? Yes No
For women check all that apply: I am pregnant I am nursing I am taking birth control pills
Have you experienced an unusual reaction to any of the following?
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. Moreover, I accept the courtesy Dr. Beagle’s office offers in submitting insurance claims on my behalf. I hereby authorize the release of any information relating to said claims, and authorize as well, payment directly to Dr. Beagle’s office of the group insurance benefits, otherwise payable to me. Moreover, I understand that this filing is done as a courtesy and that I am responsible for all cost of dental treatment.