I grant authority to Nathan P. Tenney, D.M.D. to perform dental and surgical procedures and treatments, including the administration of medicines and local anesthetics that are deemed necessary and advisable for this patient. Patient and/or legal guardian/parent will be informed before any treatment is performed. I authorize the release of any information necessary to expedite insurance claims, I understand that I am ultimately responsible for ANY and ALL charges, regardless of insurance coverage. I hereby certify the above to be true and correct to the best of my knowledge.
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Are you allergic to any of the following?

Do you have, or have you had, any of the following?
AIDS/HIV Positive *
Alzheimer’s Disease *
Anaphylaxis *
Anemia *
Angina *
Arthritis/Gout *
Artificial Heart Valve *
Artificial Joint *
Asthma *
Blood Transfusion *
Braces *
Breathing Problems *
Bruising Easily *
Cancer *
Chemotherapy *
Chest Pains *
Cold Sores/Fever Blisters *
Convulsions *
Convulsions *
Cortisone Medicine *
Congenital Heart Disorder *
Diabetes *
Diabetes *
Drug Addiction *
Easily Winded *
Epilepsy or Seizures *
Emphysema *
Excessive Bleeding *
Excessive Thirst *
Fainting Spells/Dizziness *
Frequent Cough *
Frequent Headache *
Glaucoma *
Hay Fever *
Hearing Impairment *
Heart Attack/Failure *
Heart Murmur *
Heart Pacemaker *
Heart Trouble/Disease *
Hemophilia *
Hepatitis A, B, C *
Herpes *
High Blood Pressure *
High Cholesterol *
Hives or Rash *
Hypoglycemia *
Hypoglycemia *
Irregular Heartbeat *
Kidney Problems *
Leukemia *
Liver Disease *
Low Blood Pressure *
Low Blood Pressure *
Lung Disease *
Mitral Valve Prolapse *
Osteoporosis *
Pain in Jaw Joints *
Parathyroid Disease *
Rheumatism *
Psychiatric Care *
Radiation Treatments *
Sinus Trouble *
Renal Dialysis *
Rheumatic Fever *
Scarlet Fever *
Shingles *
Sickle Cell Disease *
Sleep Apnea *
Spinal Apnea *
Stomach/Intestinal Disease *
Stroke *
Swelling of Limbs *
Thyroid Disease *
Tonsilitis *
Tuberculosis *
Tumors or Growths *
Ulcers *
Venereal Disease *
Yellow Jaundice *
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. I understand that providing incorrect information can be dangerous to my (or patient’s) health.
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