New Patient Registration Contact Information Clinical Information Date of Birth Gender* MaleFemale Pre Existing Medical Conditions: DiabetiesBlood PressureCardiac ConditionBleeding DisordersAllergiesPregnancyOther (We'll ask) Are you taking any medicines? The information provided above is totally correct and complete to my knowledge.* GENERAL CONSENT Your doctor will always act in your best interest. And the doctor will be making decisions to use medications and administer local anesthesia when necessary. Certain drugs may react differently to different people and it will be your responsibility to communicate and mention such things in this form. And the doctor will not be held responsible in any such cases. XRAYS AND PHOTOGRAPHS I understand that photographs and xrays would taken for my medical records and made available to other clinicians involved in my treatment. I allow this content to be used for teaching purposes and be put up on websites provided it is anonymized. DRUGS AND MEDICATIONS I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and or/anaphylactic shock (severe allergic reaction) I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that guarantee or assurance will be made by anyone regarding the dental treatment which I will request and authorize. I have read the consent above.* Patient (Incase of Minor guardian/parent) Signature *
