The Periodontists Confidential Questionnaire

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Fill Out the Form Below or Download the PDF​






















    Previous Dental History











    Medication and Recreational Drug Specifics & History

    To ensure we provide the best possible care, please complete the following:


    MEDICATION DECLARATION:

    In signing this form I acknowledge this represents an accurate medication history. I will advise my dentist of any changes to my medical history in the future. I understand all medical details will be treated with complete professional confidentiality. I have read The Periodontists privacy policy document











    TO BE COMPLETED BY NEW PATIENTS ONLY




    CONFIDENTIAL QUESTIONNAIRE DECLARATION:

    In signing this form I acknowledge this represents an accurate medical history. I will advise my dentist of any changes to my medical history in the future. I understand all medical details will be treated with complete professional confidentiality. I have read The Periodontists privacy policy document.






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