Your medical history can affect the success of your dental treatment and will guide us on how to provide safe treatment for you. The information you provide is completely confidential and will be handled in accordance with our privacy policy.

Before starting this form, please have on hand details of any medications you are currently taking. We encourage you to complete and submit the form within an hour to ensure successful submission. Please do not move off this page or open a new tab while completing the form as you may lose data you have already entered. 

If you’d like to receive a copy of this information simply enter your email address. If you’d prefer to complete this form offline, please arrive at the practice 15 minutes before your scheduled appointment to fill out your medical history.

  • Step 1 - Details
  • Step 2 - Emergency Contact
  • Step 3 - History
  • Step 4 - Medications

Your Details

Preferred Name
Home Phone
Work Phone
 

Required for copy to be emailed to you
Occupation
If not known, please type unknown.