Patient Registration

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Thyroid Problems
Rheumatic Fever
ALLERGIES MEDICATION Do you have allergies
High Blood Pressure
Heart Ailment
Excessive Bleeding or Blood Disorder
Epilepsy
Asthma Chest or Breathing Problems
Hepatitis
AIDSHIV
Tuberculosis
Bone Disorders or Diseases
Stomach or Bowel Problems eg Ulcer
Kidney Disease
Smoke Tobacco
Diabetes
Would you like to discuss these questions in private with the surgeon?
Do you have an artificial hip, heart valve, or other prosthetic implant?
Have you ever had problems with dental treatment?
Are you presently under medical care?
Are you taking any drugs, medicine, or tablets?
(Female Patients) Are you pregnant?
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10/19/2026Click to Sign
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