Complete the following form

1. Personal Information
Middle name:
Last name*:
Date of birth:
Periodontal Treatments Scalling root planning
Periodontal surgical procedures Prophylaxis (Cleanings)
3. Medical History
Please answer the following questions:
1-You ever suffered one or some of the following illnesses?
Heart diseases High blood pressure
Diabetes Epilepsy Coagulation disorders
Psychiatric diseases Alcoholism Ulcer/gastritis
2-How is your general health?
3-Are you taking any kind of medication? No Yes
List them
4-Have you ever have any negative experience with local anesthetics? No Yes
Please specify
5-Are you allergic? No Yes
List them
6-Do you take aspirins or products that contains it? No Yes
Which ones?
7-Do you use tobacco? Daily Occasionally No
8-Do you drink alcohol? Daily Occasionally No
9-Have you ever had any other surgery before? No Yes
Please name them and write down the dates:
10-If you have any other medical information of importance, please specify:

*Missing Fields Required


Phone Number
(506) 2258-0606
(506) 2257-9145
(506) 2257-8632

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