So that we may provide you with the best possible care, please complete both the medical and dental history forms. The following information is to be reviewed by the doctor and will be held in the strictest confidence. It is important that you complete the form in its entirety so that we may accurately diagnose and treat you, according to your general health and well-being.

What is the reason for your visit today?
Date of your last dental visit:
Date of your last dental cleaning:
When were your last dental x-rays (Bite-wings):
When were your last dental x-rays (Full Mouth Series):
What did you have done at your last dental visit?
Last Dentist that you visited:
Dentist's Phone:
How often do you visit the dentist?
How often do you brush your teeth?
How often do you floss?
Do you use any other dental aids? (Toothpick, power toothbrush, etc.) If so, what?
Do you have any dental problems now?
Do you feel nervous about having dental treatment? Have you ever had an upsetting dental experience?
If yes, please explain:
Is there anything else about dental treatment you would like us to know?
Do you experience any of the following or have you had any of the following?: (Check all that apply)
Are you satisfied with your teeth's appearence?
Would you like to keep your teeth all of your life?
Digital Signature of Patient/Legal Guardian:
Spam Verification: