Medical History Form

Name of Your Physician

Phone Number

Preferred Pharmacy

Phone Number

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment below:

Are you currently taking any medications (prescription and non-prescription) including regular doses of aspirin? if yes, please all medications and doses below:*

Yes

Medications:*

* THE FOLLOWING SECTION IS FOR EXISTING PATIENTS ONLY *

Please review and update the following information if needed. Thank You.

Chart #:

FOR OFFICE USE ONLY ↑

First Name

Last Name

Preferred Name

Title

Mr/Ms/Mrs/etc.

Gender

Male

Female

Family Status

Married

Single

Divorced

Other

Date of Birth

Prev. Visit:

Email Address

Home Phone

Mobile Phone

Work Phone

Ext

Best Time to Call

Morning, Afternoon, etc.

Address 1

Address 2

City

State

Zip Code

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Indicate which of the following conditions you have or have had.

Please explain/clarify any conditions or alerts selected above:

* THE FOLLOWING SECTION IS FOR EXISTING PATIENTS ONLY *

Please review and update the following information if needed. Thank You.