Lehigh Valley Cosmetic Dentistry
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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:
I certify that to the best of my knowledge, the questions on this form have been accurately answered. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. 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.
I will not hold Lehigh Valley Cosmetic Dentistry, my dentist, and his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form