Biria Dentistry

14364 Metcalf Ave.
Overland Park, KS 66223

Have Questions or to make an appointment:
Phone: 913-499-1111
Email: info@biriadentistry.com

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New Patient Health Form

Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

* Required

Patient Information

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on the form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.