RHU-MABINI

DENTAL RECORDS
Patient’s Name: _______________________________________________________Date:________________
Address: _____________________________________________Sex: _____________Age: _______________
Chief Complain: ____________________________________________________________________________

Medical History:
NO YES
1. Have you ever had
a) High Blood Pressure
b) Heart Disease
c) Fever
d) Diabetes
e) Goiter
f) Asthma
g) Blood Disorder
h) Epilepsy
i) Kidney Disease
j) Jaundice or Liver Problems
2. Do you have any allergies to drugs, foods or materials?
3. Have you ever had a major operation? If yes, when? _____________ what?____________
4. Have you suffered from prolonged bleeding after extraction or injury?
5. Are you taking any drugs?
6. Are you pregnant?

I hereby certify that all statements are true and correct.

I fully understand the procedure of the dental treatment, the possible consequences after treatment and the
post-operative instructions which have been well explained to me by the Dentist.

I hereby authorize any of the doctors/dental auxiliaries to proceed with & perform the dental restorations & treatment as explained to me. I understand that these
are subject to modification depending on undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental
insurance coverage I may have, I am responsible for payment for dental fees. I agree to pay any attorney’s fees, collection fee, or court costs that may be incurred
to satisfy any obligation to this office. All treatment were properly explained to me & any untoward circumstances that may arise during the procedure, the attending
dentist will not be held liable since it is my free will, with full trust & confidence in him/her, to undergo dental treatment under his/her care.

______________________ _____________ __________________________ __________________ ___________

Patient’s Signature Date Printed Name and Signature Relationship Date
Of Guardian to the Patient

__________________________ _________
Dentist License No.