206-624-9943

901 Boren Ave suite 1733
Seattle WA 98104

2

Locations

425-614-1600

1299 156th Ave NE Ste 115,
Bellevue, WA 98007

Dental History

water flosser, gum picks, gum stimulator, etc.
Name of previous dentist or dental office

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.