Please Fill This Online Form
Thank you for selecting our dental team! We will strive to provide you with the best possible dental care.
Although we primarily treat the area in and around the 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 honestly and completely.
- Patient Information
- Dental History
- Medical History
State of Origin
Are you a Student?
Name of School/College
Next of Kin
If Minor, Head of Family
Please Give Details
Name of Company
Name of Insurance Company
Registered address with the insurance company
Whom may we thank for referring you?
Date of Last Dental Care
Date of Last Dental X-Rays
Former Dentist Name
Are you having or have you had any of the following
Are you having or have you had any other concerns with your mouth and/or teeth?
How do you like your smile? Rate you smile
What, if anything, would you change about your smile?
Would you like more information on
Date of Last Visit
How long ago was your blood pressure checked?
Are you on a special diet?
If yes, explain
Do you have any or have you ever had any of the following
Heart disease/Heart surgery
Kidney disease/Kidney surgery
High blood pressure/Hypertension
Sickle Cell Anaemia
Any bleeding disorder
Are you trying or trying to get pregnant?
Taking oral contraceptives?
List all prescription drugs you currently take
List any Herbal Remedies, Multi-Vitamins, Supplements or Over the Counter Drugs you take more than 2x per week
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my [patient's] health. Is my responsibility to inform the dental office of any change in medical status.