Medical & Dental History

Boger Dental Health History Form

We are happy to have you join our great family of patients and friends.

The benefits of a healthy, beautiful smile are immeasurable, and our goal is to allow you to obtain the healthy teeth and attractive smile you want and deserve.

Please complete this form so that we can provide the best care possible for you. Thank you!

ABOUT YOU
Please provide the patient's name.
Please provide the patient's address.
Please provide the patient's city.
Please provide the patient's state.
Please provide the patient's zip.
Please provide a valid email.
EMERGENCY INFORMATION
DENTAL INSURANCE INFORMATION
MEDICAL HISTORY

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.

Do you have, or have you had, 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.

Dental HISTORY

Please share the following dates:

Please check any of the following that apply to you:

On a scale of 1-10, with 10 the highest rating

I would like to learn more about:

Release of Information and Assignment of Benefits
I , authorize release of information for all covered services and for those benfits to be paid directly to Boger Dental PA. I further agree to be responsible for all charges for services and materials not covered or paid by my dental benefit plan.
Initials

Appointment Policy
Boger Dental is pleased to offer appointments which are reserved specifically for you. We reserve the time and prepare in anticipation of serving you. In the unlikely event that you are unable to keep your appointment, please notify us as soon as possible (more than 2 business days). We understand that conflicts arise and hope you understand that failing to give adequate notice more than once may result in a $100 cancellation charge or disconcinuation of services.
Initials

2720 Annapolis Circle N., Suite A, Plymouth, MN 55441
 | 763-546-7707 phone | 763-546-7713 fax | BogerDental.com