Medical History Form 
Are you pregnant
Nursing?
Taking birth control pills?
Indicate which of the following you have had, or have at present? (Check all that apply).
Do you smoke?
Do you use alcohol?
Do you use recreational drugs?
Have you had surgery or been hospitalized in the last 5 years?

Your Signature

 Dental Implants in  Forest Park, IL
  • Black Facebook Icon
  • Black YouTube Icon
  • Black Instagram Icon
 Dental Implants in  Forest Park, IL

333 Circle Avenue, Forest Park, IL 60130

Copyright © 2019 Platinum Dental Care. All Rights Reserved. Designed & Developed by Middleground Marketing