Medical History

Please complete the form below, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

Become a Patient

Medical History Form

Please fill out our medical history form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

Step 1 of 2

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.

If you answer yes to the following questions, please explain on the blank provided.

Do you have, or have you had, any of the following?