Seattle Cosmetic Dentist - Advanced Cosmetic Laser Dentistry

Please complete each of the following three new patient forms listed below prior to your initial visit.

· Tell us About You

· Questionnaire

· Health History

If you'd rather bring the forms with you to your appointement, please download and print the following PDF forms.

· Tell us About You (PDF)

· Questionnaire {PDF)

· Health History (PDF)

Name:*		Date:		(mm/dd/yy)
Email: *		Phone:*:

General Health

Are you in good health?

YES

Are you currently under the care of a physician?

YES

If yes, please explain

Physician's name

Physician's phone

Please list all the medications currently being taken

Do you smoke or use tobacco in any form?

YES

WOMEN ONLY:

Are you pregnant?

YES

If so, what is your due date?

(mm/dd/yy)

Are you nursing?

YES

Are you using birth control pills?

YES

Have you ever had any of the following? Please answer each one.

Are you allergic to reacted adversely to any of the following?

Is there anything additional you feel is important for us to know about your health?