• Medical History Questionnaire


  • IN CASE OF EMERGENCY, WE SHOULD NOTIFY:




  • The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form (both sides)



  • To the best of my knowledge, the above information is correct

  • Clear
  • Clear
  • form_phipa

  • Should be Empty: