Welcome to Heritage Dental Hygiene!
For ages 16 years and older please complete this medical & dental history form before your appointment. 
Have you been diagnosed wih Hepatitis A, B or C or HIV Aids?
Upload Medication List
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Have you been diagnosed with diabetes?
How many times a year do you have your teeth cleaned?
Do you have a dry mouth?
Would you like to have whiter teeth?
The toothbrush I use most is
How often do you floss?
Do you use mouthwash?
Submit Any Additional Records Here!
Upload supported file (Max 15MB)

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