BlissDental Your Kendall General Dentist

(305) 274-6500

  • Dental Services
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(305) 274-6500
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Dental History Information

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For woman only

Are you taking birth control pills?
Are you nursing/breastfeeding?
Are you pregnant?
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Is there a possibility of pregnancy?

NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.


Dental History Information

Do you snore?
Do you have problems with bad breath?
Have you ever had an allergic reactions to a crown, metal filling or dental appliance?
Have you ever had an oral cancer screening?
Have you ever used an electric toothbrush?
 
On a scale from 1 to 10, with 10 being the highest
Are your teeth sensitive to hot, cold or pressure?
Do your gums bleed when you brush?
Have you ever had complications from an extraction?
Are you prone to frequent headaches?
Do you grind or clench your teeth?
Do you have sores, blisters or swelling on your gums lips or cheeks?
Have you ever had orthodontic treatment?
Have you ever had a popping or clicking near your ear when you chew?
Have you or a family member ever been treated for periodontal disease?
If you could change something about your smile what would it be:

I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

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This field is for validation purposes and should be left unchanged.

BlissDental Your Kendall General Dentist

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5 stars from 275 reviews

Contact Info

  • 8501 SW 124th Ave Ste 104
    Kendall, FL 33183
  • Phone: (305) 274-6500
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Hours of Operation

Monday: 9:00AM to 5:00PM
Tuesday: 9:00AM to 7:00PM
Wednesday: 9:00AM to 5:00PM
Thursday: 9:00AM to 5:00PM
Friday: 9:00AM to 5:00PM
Saturday: 8:00AM to 2:00PM *
Sunday: Closed

*first Saturday of the month