Patients Form

Patient registration form.
The information will be confidential and for the exclusive use of the clinic. In case the patient is a minor, he must be accompanied by his parents.




    FemaleMale

    Day Month Year


    años












    FlossMouthwashNone

    HeatColdSweetsNone

    YesNo


    HabitualOccasional


    YesNo


    WeeklyBiweeklyMonthlyOccasional


    YesNo




    YesNo


    NoneMedicinesAntibioticsLocal AnesthesiaLatexAINESOthers


    Please indicate if you have the following symptoms

    NoneFaintingChemotherapyAbnormal bleedingAnemiaHemophiliaKidney DiseaseGlaucomaCancer or TumorRespiratory ProblemsPaceMakerHeart SurgeryHeart conditionArthritisRheumatic FeverOrgan TransplantChest PainTuberculosisHigh blood pressureConvulsionsOsteoporosisJoin ReplacementDiabetisHepatitisGastritisUlcersColitisEpilepsyHIV-SIDAArterioesclorosisHeart Murmor*

    * Some heart Murmur require pre-medication for Dental care. Please check with your Physician.



    If you have additional information you want to share, please fill the box below:

    I understand that this medical history is a legal document and that I have answered all of the above questions to
    the best of my ability and knowledge. All of the preceding answers and information provided are true and correct
    If I ever have any changes in my health, I will inform the Doctors at the next appointment without fail, I will not
    hold my Dentist or any other staff members responsible for any errors or omissions I have made in the completion
    of this form. I authorize Nova Dental to use my case and photographs for teaching and promotional purposes. I am
    informed about my rights and responsabilities as a patient. I am aware that my dental work will be guaranteed at
    Nova Dental in San Jose, Costa Rica only.

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