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  • ABOUT US
  • TREATMENTS
  • RESOURCES
    • BLOG
  • FORMS
    • FOR PATIENTS
    • FOR DENTISTS
  • CONTACT
  • BOOK NOW
  • ABOUT US
  • TREATMENTS
  • RESOURCES
    • BLOG
  • FORMS
    • FOR PATIENTS
    • FOR DENTISTS
  • CONTACT
  • BOOK NOW

Dental History Form

Dental History Formdev@medianv.com2022-02-05T11:14:59-07:00

Patient Dental History

I have routinely seen my dentist every

How would you rate the condition of your mouth? *

Gum and Bone

Please select all that apply to you:

Tooth Structure

Please select all that apply to you:

Bit and Jaw Joint

Please select all that apply to you:

Smile Characteristics

Please select all that apply to you:

Medical History

Do you or have you ever had hospitalization for illness or injury?

Do you or have you ever had an allergic or bad reaction to any of the following:

Please select all of the following that you have or have ever had:

Please select any of the following that apply to you:

Please advise the office in the future of any change(s) in your medical or dental history as well as medications you may be taking.

Jensen Lakes Dental logo

215 – 840 St. Albert Trail St. Albert, AB T8N 7V2
780-347-8080
info@jensenlakesdental.com


HOURS

Tuesday to Friday

9:00AM - 5:00PM

Saturday

9:00AM - 4:00PM

Sunday & Monday

CLOSED

Treatments

Veneers
Dental Implants
Dental Crowns
Gum Grafting
Teeth Cleaning and Prevention
Teeth Whitening
Dental Bridges
Bone Grafting
Composite Restorations

Treatments

Crown Lengthening
Digital Smile Design
Extractions
Full Mouth Rehabilitation
Implant-supported Dentures
Periodontitis Treatment
Piezocision
Peri-implantitis Treatment

Quick Links

Blog
Smile Gallery
Doctor Referral Form
Patient Information Form
Dental History Form
General Consent Form


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