Medical History Form

Simply fill out the form below and send it straight to our office right from your phone or computer! Prefer to use our PDF form to fill out and email/print a hard copy? Access that here!

Personal Information
Name *
Name
Address *
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Date of Birth *
Date of Birth
Employment & Insurance
Patient's Relationship to Insured
Family Doctor's Phone Number
Family Doctor's Phone Number
Medical Specialist's Phone Number
Medical Specialist's Phone Number
Dentist's Phone Number
Dentist's Phone Number
Emergency Contact's Phone Number
Emergency Contact's Phone Number
Dental History
Date of Last Dental Visit *
Date of Last Dental Visit
Date of Last Cleaning *
Date of Last Cleaning
Do you have full or partial dentures? *
Do you have any pain in your teeth or gums? *
Are your teeth sensitive to hot, cold, sweets or pressure? *
Are you interested in having whiter teeth? *
Are you happy with your smile? *
Have you ever had gum surgery? *
Do you have dental implants? *
Medical History
Do you have a prosthetic or artificial joint?
WOMEN: Are you Pregnant?
WOMEN: Do you take Birth Control Pills?
WOMEN: Do you take a hormone supplement?
Indicate which of the following you presently have or have ever had: 

Check all that apply
Do you currently have, or have you had in the past, any disease, condition or problem not listed above?
Can we send you occasional updates about your dental hygiene to your email address? *
GENERAL RELEASE *
By submitting this form, you certify that you have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. You have had the opportunity to ask questions and receive any questions regarding your medical – dental history. Should there be any change in either your health status or any other information you have provided, you will advise the dental hygienist. You authorize the provider to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment. You understand that information provided from, or to, your medical doctor or another health provider may be necessary. This office has a privacy policy that protects your personal information. You understand that responsibility for payment of the dental services for yourself and your dependents is yours, and you assume responsibility for fees associated with these services.