Medical History

Medical History

Radiant Dental

6200 Wilshire Blvd. #1706 Los Angeles, CA 90048
323-937-5666

Medical History

Patient Details

Date of Birth:

Gender:
Marital Status:

HEALTH HISTORY

Are you currently under the care of a physician?
Have you ever been hospitalized or had a major operation?
How would you rate your physical health? (Please select one)
Have you undergone placement of any metal rods, pins, or implants?
Have you ever had a serious head or neck injury?
Do you take, or have you taken, PhenFen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Do you use tobacco in any form?
Do you use controlled substances?
Are you on a special diet? *

MEDICAL HISTORY

Do you have allergies to any of the following?
Do you have, or have you had any of the following medical conditions?
Are you currently taking any of the following medications?

Date:

We promise to provide our patients with the ultimate care in Cosmetic Dentistry. This includes delivering the highest quality of technical care and treating our patients with respect, courtesy and compassion.

All regular and PPO insurances are accepted except Medical and HMO.