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

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