Medical History Form

We ask everything in this form because the answers shape your care. Please be candid. The information is private to the studio's clinical team.

Personal details

• ·Full name
• ·Date of birth
• ·Preferred contact (email, WhatsApp)
• ·Emergency contact
• ·Primary physician

Medical history

• ·Current medications, including supplements and herbal preparations.
• ·Allergies — medications, latex, materials.
• ·Cardiovascular history, including any heart valve or pacemaker.
• ·Diabetes or other endocrine condition.
• ·Blood-thinning medication.
• ·Bisphosphonate medication (current or in the past five years).
• ·Pregnancy or breastfeeding.

Dental history

• ·Previous dental treatment — implants, root canals, periodontal work.
• ·Any previous reaction to local anaesthesia.
• ·History of bruxism, clenching, or temporomandibular joint pain.
• ·Current dental concerns in your own words.

What happens next

The treating dentist reviews this form before your visit. Anything in the answers that needs a phone call before the visit, we will call. Anything that needs follow-up during the visit, we will discuss in person.