Cosmetic Dentistry Medical History Form

Personal Information

Full Name

Date of Birth

Email

Phone Number

Address

Are you currently under the care of a physician?

Yes No

If yes, please specify the condition(s) and medication(s):

Have you had any surgeries (including dental) in the past 5 years?

Yes No

If yes, please list surgeries and dates:

List current medications and supplements:

List any allergies (including drug allergies):

Do you have or have you ever had any of the following:

Diabetes High Blood Pressure Heart Disorders Bleeding Disorders

Asthma Hepatitis Epilepsy/Seizures None

What would you like to improve about your smile?

Have you had previous cosmetic dental treatments?

Yes No

If yes, please describe:

Are you satisfied with the appearance of your teeth?

Yes No

Is there anything else we should know regarding your cosmetic dental needs or medical history?