PATIENT DENTAL HISTORY INFORMATION I certify that I have read and understand the information on this form. I acknowledge that I have answered the questions correctly and to the best of my ability, and that any questions that I had have been answered to my satisfaction. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Patient or Legal Guardian Name: Relationship to Patient: