Clean Smiles Dental Hygiene Clinic

Patient Medical History Form

Please note: Prior to any dental treatment, our office requires a complete medical history. Knowing any health problems and/or medications you may be taking can avoid problems when treatment commences. Thank you for taking the time to answer these questions.




















    For Women Only:



    Are you allergic or have you had a reaction to:









    Do you or have you ever had the following:



































    or