Medical/Dental Health History Form
Please complete all fields accurately
Personal Information
Full Name
Date of Birth
Healthcare Providers
Primary Care Physician
Physician's Phone
Specialists (if any)
Current Medications
Add Medication
Health Conditions
High Blood Pressure
Diabetes
Heart Disease
Arthritis
Asthma
Cancer
Current/Past Opioid Use
Bleeding Problems
Other Conditions
Reason for Visit
Please describe your current dental concerns
I certify that the information provided is accurate and complete to the best of my knowledge
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