Dental History Form

Please check any of the following problems that apply to you:

(Check all that apply)

Do you have or have you had any of the following?:

Please share the following dates:

If you could change your smile, you would:
On a scale of 1-10, with 10 being the highest rating:


Do you have an allergy to any of the following?
What surgeries have you had? Please include dates.