Medina County Health Department Dental Services

Attention: Information that is exchanged through this Patient Portal is secure. .

First Name * Last Name * Date of Birth * Are you currently under the care of a physician? * Do you have latex allergies? Are you allergic to any drugs? Do you have any food allergies? Have you received any prescription pain medication in the last 30 days? Do you wear contact lenses? Do you need to be pre-medicated prior to your dental treatment?

Have you ever had any of the following diseases or medical problems?

PLEASE CHECK ALL THAT APPLY. Have you ever experienced any serious medical condition not listed above?

WOMEN ONLY

Are you pregnant or think you might be pregnant? Are you nursing/breastfeeding? Are you taking birth control?