Patient's Dental History Report

Personal Information

Provide as much information as possible to evaluate your health.
Upload File, photos or x-rays of your teeth or mouth
Max File Size 15MB
What kind of transportation do you have to use to get here?
Do you need to stay and need help with your hotel reservation?

Medical History

Have you had any Dental treatment before?
Diabetes?
Hypertension?
High blood pressure?
Blood transfusions?
Heart Disease?
Venereal Diseas?
Tumor/Cancer?
Epilepsy or seizures?

Current Medication