Ascot Dental | Medical History Form

Medical Dental History Form

It is important to know details about your medical history as these could affect the success of oral health care (dental treatment). The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the reverse of this form.

Medical History Form

Medical Dental History Form

Do you have, or have you ever had, any of the following medical conditions?

Have you ever had any teeth extracted? If so: