Medical History Form
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You just completed the Medical History Form, we hope to get a hold of you soon!

Patient Information

Fields marked with an asterisk (*) are required.

How did you hear about our office?

If other, please explain

If you heard us on the radio, please let us know which station:

Dental Insurance Information

If you have secondary insurance, please fill out the information below.

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following which apply to you, and add any relevant comments.

If yes, please list all medications you are currently taking.

If yes, please explain.

If yes, when did this occur and what was performed?

If yes, when?

Are you allergic to the following?

If other, please explain.

Please check any of the following that you have had or currently have

If yes, when was it placed?

If yes, when?

If yes, when?

If yes, when?

If yes, when?

If yes, when?

If yes, when was it placed?

If yes, when?

If yes, when?

Are there any medical conditions we have not discussed that you feel we should be aware of?

If yes, what kind?
If yes, how much?

If you're pregnant, how many weeks?

Dental History

What concerns you most about your teeth?

Please check any of the following which apply to you, and add any relevant comments

Captcha

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

We make you smile

The Friendliest and Most Gifted People in the Dental Business

I never feel like just another patient when I visit this clinic. These folks are genuinely interested in my dental health and general well being. Regis Court Dental Associates is truthfully the best dental care facility I've ever been to as a patient.

- Tony P.

Sedation Density Before & After