Medical History Form

About You


Your Medical History

Have you ever had any of the following? Please tick those that apply:*
Do you smoke?

Your Dental health

MM slash DD slash YYYY
Please tick any dental concerns that you have:
Do you feel nervous about your dental treatment?
Do you usually require antibiotics before dental treatment?
Have you ever had any adverse reaction to dental treatment?
Have you had your wisdom teeth removed?
Are you interested in whitening or cosmetic treatment?
How did you hear about us*
This field is for validation purposes and should be left unchanged.

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