Medical History Form

Please make sure to read our Dental Insurance Facts.

(*) - Required field

Patient Information

Full Name
If Child, Parent's Name
Phone Number
E-Mail Address
Physician Name
Date of Last Physical
Reason for Visit

Are You Currently Under a Physician's Care?

Have You Ever Been Hospitalized?

Date of Last Dental Visit
Date of Last Dental X-Ray
If Wearing Dentures, Age of Dentures

Ever Had Novocaine or Other Local Anesthetic?

Are You Taking or Have Taken Steroid or Cortisone Therapy?

Are You Taking or Have Taken Any Oral Bisphosphonates?

Are You Taking or Have Taken Any IV Bisphosphonates (Aredia, Zometa, Bonefos)?

Have You Taken Antibiotics Prior to Dental Procedures in the Past?

Are You a Smoker?

If So, How Much Do You Smoke? Or, How Long Ago Did You Quit?

Are You Pregnant?

If Pregnant, Your Estimated Delivery Date?

Are You Currently Nursing?

Please List All Medications You Are Allergic To

Have You Had an Adverse Reaction or Become Ill to Penicillin, Aspirin, Codeine, Local Anesthetics, Latex, Metals, or Any Other Medication or Substance?

Please List All Medications You Are Currently Taking

Do You Currently Take Fish Oil, Vitamin E, Omega 3, Plavix, Coumadin, Xarelto, or Aspirin Daily?

Consume More Than One Alcohol Based Drink Daily?

Do You Have Any Of The Following Problems With Your Mouth or Teeth? (Check All That Apply)

Medical Information

Services Requested

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