Dental Cleaning Release Form

Capture the patient's relevant medical history and secure their signature before a dental cleaning.

Use this template

Name

Nombre

Apellido

Phone Number

Email

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Are you currently under the care of a physician?

Yes No

If yes, please provide the name and contact information of your physician

Do you have any allergies to medications or materials used in dental procedures?

Yes No

If yes, please specify

Are you currently taking any medications?

Yes No

If yes, please list medications

I certify that the information above is accurate and authorize the dental cleaning, releasing the practice from liability for any reaction related to my medical history.

Patient Signature

Sign here

Date Signed

Dental Cleaning Release Form

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