Skip to content
About Us
Expand
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Expand
Cosmetic Dentistry
Expand
Restorations
Expand
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Expand
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Expand
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
Expand
New Patient Form
X-Ray Release Form
Contact Us
Book Now
Toggle Menu
Medical Information Update Form
Step
1
of
2
- Medical Information
50%
Name
(Required)
First Name
Last Name
Date of Birth
(Required)
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Do you have any serious Medical Conditions we should know about?
(Required)
Yes
No
Please explain.
Known Medical Conditions
Alcohol/ Drug Abuse
Angina
Arthritis
Asthma
Blood Disorder
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Dizziness/Fainting
Emphysema
Epilepsy/Seizures
Frequent Headaches
Gag Reflex
Hay Fever
Head Injuries
Hearing Disabled
Heart Attack
Heart Murmur
Hemophilia
No Known Medical Issues
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
Hepatitis A/B/C
High Blood Pressure
HIV/AIDS
Joint Replacement (hip, knee, etc)
Kidney Disease
Liver Disease
Low Blood Pressure
Lung Disease/ Tuberculosis
Mental Disorder
Mitral Valve Prolapse
Multiple Sclerosis
Pacemaker
Radiation Therapy
Respiratory Problems
Sinus Problem
STD
Stomach/Intestinal Problems
Stroke
Thyroid Disorder
Ulcer
Other
If Other selected, please specify:
(Required)
Do you have any allergies to medication or substances?
(Required)
Yes
No
What Allergies do you have?
Are you taking any prescription medication or herbal remedies? (including cannabis)
(Required)
Yes
No
Please list off your medications
(Required)
Do you need to be medicated with antibiotics prior to dental treatment
(Required)
Yes
No
Do you smoke or use chewing tobacco?
(Required)
Yes
No
Have you ever been treated for any other illness not listed above?
(Required)
Yes
No
If Yes selected, please specify:
(Required)
Are you pregnant and/or nursing?
(Required)
Pregnant
Nursing
No
How far along is your pregnancy?
(Required)
Have you recently been under the care of a physician?
(Required)
Yes
No
Name of Physician
(Required)
Physician's Phone Number
(Required)
When was your last visit with the physician?
(Required)
Current Health Condition
(Required)
Excellent
Good
Fair
Poor
Signature
(Required)
Dentistry Made Simple.
Thanks For Filling Out Our Form.
About Us
Toggle child menu
Expand
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Toggle child menu
Expand
Cosmetic Dentistry
Toggle child menu
Expand
Restorations
Toggle child menu
Expand
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Toggle child menu
Expand
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Toggle child menu
Expand
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
Toggle child menu
Expand
New Patient Form
X-Ray Release Form
Contact Us
Book Your Appointment
Phone
