Are you under the care of a physician for a specific condition?
Have you been hospitalized during the past three years?
Are you taking any drugs or medicine?
Have you ever had an unfavorable reaction from a local anesthetic?
Have you ever been told to take antibiotics prior to your dental appointments?
Do you have or have you had any of the following, please mark the box:
Do you have any disease or condition not listed?
(Women) Are you pregnant or nursing?
(Women) Do you take birth control pills?
Are you nervous or anxious in the dental office?
If so, would you like to be treated with Nitrous Oxide?

CONSENT FOR TREATMENT: The above health history is correct to the best of my knowledge. I authorize and give consent for dental services agreed to by Doctor and Patient and/or Guardian, including the use of local anesthesia and other medications as indicated.