The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.
Are you currently taking any medications (including aspirin, birth control, herbal medications,etc?)
Do you smoke?
How many per day?
Are you currently being treated for any condition not listed?
Please specify
Have you ever used or currently using Vitamin A or Glycolic acid?
Have you ever used or currently using Accutane?
Have you ever had a chemical peel?
Have you ever had laser treatment?
Have you ever been treated by an Endocrinologist?
Do you sunbathe or use self tanning lotions or use tanning beds?
Please specify and how often?
Are you currently pregnant, breast feeding or do you plan to become pregnant in the next year?
I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician or pharmacist being contacted if necessary to obtain information that is required for my dental care.
