Cosmetic Dentistry History Form
Patient Information
Full Name
Date of Birth
Phone
Email
Address
Dental History
Have you had any of the following? (Check all that apply)
Veneers
Crowns
Teeth Whitening
Braces/Orthodontics
Implants
Bonding
Other Cosmetic Treatments
What are your main cosmetic dental concerns?
What are your expectations?
Medical History
Physician Name
Physician Phone
Allergies
Current Medications
Medical Conditions
Additional Notes