TAMBORELLO DENTISTRY

6875 FM 1488 Suite 600
Magnolia, Texas 77354
Phone: (281) 252-6882
Fax: (281) 259-6234

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide the best possible dental care. To help us meet all our dental healthcare goals, please fill out this form completely. If you have any questions, please ask. We will be happy to help.

Patient Information (Confidential)

Patient Medical History






In an effort to "Go Green" we are requesting cell phone numbers and e-mail addresses to text and e-mail our patients.
If you choose NOT to be contacted in this manner please let us know.

Have you ever had any of the following?

High blood pressure
Heart Attack/Year
Rheumatic fever
Swollen ankles
Fainting/Seizures
Asthma
Low blood pressure
Heart trouble
Epilepsy/Convulsions
Leukemia
Easily winded
Stroke/Year
Hay fever/allergies
Tuberculosis
Diabetes
Respiratory trouble
Kidney Disease
AIDS or HIV infection
Thyroid problem
Heart Disease
Cardiac pacemaker
Angina
Heart murmur
Mitral valve prolapse
Frequently tired
Radiation therapy
Glaucoma
Recent weight loss
Liver disease
Anemia
Emphysema
Other
Cancer
Arthritis
Joint replacement or implant
Hepatitis/Jaundice
Sexually transmitted disease
Stomach trouble/ulcers
Chest pain

WOMEN ONLY

Are you pregnant or think you may be pregnant?
Are you nursing?

AUTHORIZATION & RELEASE

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



Yes
No