NEWPORT BEACH DENTAL CENTER

Laura Sharbash

1441 Avocado Ave, Ste 606 Newport Beach, CA 92660

(949) 760-9212

Medical History

Are you currently being treated by a physician for a specific condition?(Required)
Have you recently been hospitalized or had a major operation?(Required)
Have you ever had a serious head or neck injury?(Required)
Are you taking any medications, pills, or drugs?(Required)
Are you on a special diet?(Required)
Do you use tobacco?(Required)
Have you ever been advised that you require antibiotics prior to a dental appointment?(Required)
Do you take, or have you taken, PhenFen or Redux?(Required)
Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?(Required)
Have you recently used controlled substances?(Required)
Have you recently consumed alcohol?(Required)
Women (Please check all that apply)
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic)
Do you have, or have you ever had any of the following medical conditions? (Please select all that apply)
By providing a mobile number, I agree that Newport Beach Dental Center may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.

Get in Touch

Name(Required)
By providing a mobile number, I agree that Newport Beach Dental Center may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.