Dental and Health History Form

Quinn Dental Health and History

Dental History

Medical History



I understand all of the above information is necessary to provide me with dental care in a safe and efficient manner. To the best of my knowledge, the above information is complete and correct. I also understand that it is my responsibility to inform the staff of any changes in my or my minor child's health.
By filling out your name and the date above and clicking submit you are giving us permission to have all the information on this form.