In the past year, if your PERSONAL INFORMATION has changed please clarify below. If not, skip to MEDICAL HISTORY.
Personal Information
Medical History
Centenary Dental will ensure that all information collected will be used for internal use only and will be kept secure and confidential. I consent to allow Centenary Dental to share my personal information with dental specialists if needed for the benefit of my care or to contact my medical doctor(s) if further information is needed to ensure my safety.