Aesthetics & Prosthodontics Dentistry, LLC
849 Lincoln Avenue
Glen Rock, NJ 07452

Medical History

How would you describe your present medical health?
For women:
Are you taking birth control pills?
Are you pregnant?
Are you nursing?
Do you smoke?
Have you ever had:
Are you allergic to any of the following?
Have you ever bad any of the following diseases or medical problems?