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Dental Health History (English)

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet your dental health care needs, please fill out this form completely in ink. If you have any questions or need assistance,please ask us. We will be happy to help!

Patient Information (CONFIDENTIAL)

Patient Medical History

Women Only:

Are you allergic to or have you had any reactions to the following?

Do you have or have you had any of the following? (Please check all that apply)

Patient Dental History

Authorization

I certify that I have read and understand the above information to the best of my knowledge.  The above questions have been accurately answered.  I understand that providing incorrect information can be dangerous to my health and the health of others. 

This health center receives HHS funding and has Federal Public Health (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

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Contact Us

To make an appointment, please contact one of our convenient locations...

Portales: (575) 356-6695
ENMU: (575) 562-2321
Clovis: (575) 769-0888
Roswell: (575) 623-3255
Roswell Pediatrics: (575) 622-5956
ENMU Roswell: (575) 624-7106
Roswell Behavioral: (575) 755-2272