Medical & Dental History FormFirst NameLast NameEmailPhone/Mobile. Are you currently under a physician’s care? Yes NoAre you currently taking any medications or supplements? Yes No Do you have any known allergies (e.g., medications, latex, anesthesia)? Yes No Do you smoke or use tobacco products? Yes NoDo you consume alcohol? Yes NoAre you pregnant or breastfeeding? (for female patients) Yes NoWhen was your last dental check-up?Are you currently experiencing any dental issues? Yes NoAre you anxious or fearful about dental visits? Yes No I have read and agree to the Terms and Conditions and Privacy PolicySubmit Form