Medical history form for Portner Pittack

Like all dentists, we ask patients for information about their general health to help us treat them safely. Please answer the health questions below and we will check the form at later visits so that you can tell us whether there have been any changes in your general health. All information will be kept strictly confidential by the people caring for you.

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Patients Details

Doctor's Details

Are you currently


Have you had


Do you


Did you, as a child or since, have







Smile Check




General Questions


Thank you for taking the time to answer our questions.


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