Dental History Form

Adapt this simple Dental History Form Template to collect your patients’ dental information.

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Name *

First

Last

Email *

Previous Dentist (if any)

Layout

Previous Dentist Email

Previous Dentist Phone

Previous Dentist Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Do you have any chronic medical conditions? *

• Yes
• No

Please list them below:

Are you currently on any medication? *

• Yes
• No

Please list them below:

Do you have any allergies? *

• Yes
• No

Please list them below:

Have you ever undergone dental surgery? *

• Yes
• No

Your previous dental surgery was on:JawGumsTeethLipsOther

Please share any other details of previous dental surgery:

Please share any other relevant information:

Submit