Medical History Form

Please fill the following form with the current data, this will speed up the consult process.

All required fields have been marked with a *. If you answered Yes to a required field, please fill all fields relevant to the previous required question, even if those fields are not marked as required.

General Data

For the following questions, select yes or no, whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Medical Data


I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or emissions that I may have made in the completion of this form.

If you don't have them yet, you can print your EKG and blood analysis solicitude or save your solicitude to print them later