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.

Please fill all required fields *

Patients Details

















Doctor's Details





Are you currently


 

Have you had


 

Do you


 

Did you, as a child or since, have


 

Smoking

 

Drinking

 


 

Smile Check


 

 



 

General Questions



 

Thank you for taking the time to answer our questions.

Security

Captcha image