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
    © 2021 Tamborello Dentistry | Privacy Policy | Web Design, Digital Marketing & SEO By Adit