apelgrendental.com-Dental and Health History

Apelgren Dental
3938 Cedar Grove Pkwy.
Eagan, MN 55122
651-452-9660

DENTAL AND HEALTH HISTORY
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for visit
Date of last dental visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Former Dentist
Date of last dental x-rays

MonthDayYear
2 digit month, 2 digit day, 4 digit year
DENTAL HISTORY
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MEDICAL HISTORY
Other
ALLERGIES
Type a question

Other
MEDICATIONS
Please list medications you are currently taking:
Pharmacy name
Pharmacy phone
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: