Patient Forms - Medical History

Your medical history is important to update each visit. We understand our health might have changed since your last visit; please update your medical history and either submit it to our office online or bring it with you to your next visit.

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problem that you may have, or medication that you may be taking, could have an import interrelationship with the dentistry you will receive. Thank you for answering the following questions.

If you check any of the following questions, please explain on the blank provided.

Are you allergic to any of the following?
Women: Are you?
Please select any condition you have or have had.

Please list any other serious illness.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's health). It is my responsibility to inform the dental office of any changes in my medical status.

Your Signature

Welcome to Lisa Gitelson
Welcome to our practice
Families Welcome
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OFFICE HOURS

Monday 8:00 am - 5:00 pm

Tuesday-Wednesday 7:00 am - 5:00 pm

Thursday 7:00 am - 4:00 pm

 

ADDRESS

 

14300 SW Pacific Highway

Tigard, OR  97224

503-639-4330

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© 2021  Lisa Gitelson, DMD