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Health History Form

At Lake Dental, your health is our primary concern. An important first step to providing quality dental care is getting to know you and your health. Please fill out the appropriate health history form below. Please bring any current x-rays or dental records also if you have them available. Records can be transferred from another office. Please discuss this with our office for more options.

The information that you provide is vital to help ensure your safety and promote optimal dental health. Please fill in all sections completely to the best of your knowledge. A thorough understanding of your past medical health issues can be crucial in the treatment you receive in our dental office. If there are any questions that you would like to discuss with Dr. John or Dr. Deborah privately, they will gladly accommodate you.

It is a well-established fact that dental health and total body health are closely linked. It is impossible to have good total health while neglecting your oral health. Gum infection has been linked to a variety of systemic diseases such as: heart disease, strokes, diabetes, Alzheimer's, pulmonary disease, low birthweight babies and even some forms of cancer. This vital information about your health and medications will help us safeguard you.

You have the option to:

  • Fill out these forms online and submit using our secure email button
  • Fill out these forms online and print them to bring with you to your appointment
  • Print the form to fill out by hand and bring with you to your appointment


No interest and reasonable financing options available through Care Credit

Visit the CareCredit website

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