Pre-Implant Dental Medical History Form
Patient Information
Full Name
Date of Birth
Phone
Email
Address
Medical Information
Are you currently under a physician's care?
Yes
No
If yes, please explain
Are you taking any medications?
Yes
No
If yes, please list
Do you have any allergies?
Yes
No
If yes, please list
Medical Conditions (check all that apply)
Diabetes
Hypertension
Heart Disease
Bleeding Disorders
Osteoporosis
Other
If other, please specify
Dental History
Have you had dental implants before?
Yes
No
Do you have any history of gum disease?
Yes
No
Do you use tobacco?
Yes
No
Reason for seeking dental implants
Additional Information
Please provide any additional information relevant to your medical or dental history