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Mon-Fr: 9:00 AM – 4:00 PM

6800 MONTGOMERY BLVD NE # C Albuquerque, NM 87109

New Patient Form

Medical History
Although dentistry treats primarily the area in and around your mouth, your mouth is a part of your entire body. We believe in the importance of treating the patient holistically. Therefore, other health problems or medications that you may be taking could be relevant to your dental care. Thank you for answering the following questions.



Women


Are you allergic to any of the following?


Do you have, or have you had, any of the following? Please check all that apply and circle the appropriate diagnosis.


To the best of my knowledge, I have answered the questions on this form accurately. I understand that it is my responsibility to inform the dental office promptly of any changes in overall health or medical status.