New Patient

Your health history is very important to us.

In order that we may provide you with the best possible dental services, please answer all questions completely and accurately as incorrect information may compromise your treatment. This Health History Questionnaire will become a part of your dental treatment record and is considered “Confidential.”

How did you hear about us?

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Country of residence(*)

Canada

Mexico

USA

Other

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Country where you Reside

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Visiting Manzanillo?

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Name(*)

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Birth Year(*)

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Birth Month(*)

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Day of the Month you were born(*)

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Salutation(*)

Mr.

Mrs.

Ms.

Dr.

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Gender(*)

Male

Female

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Address(*)

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Colony

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City(*)

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Province / State(*)

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Postal Code / Zip(*)

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Phone #s - Please select all that apply(*)

None

Mobile Phone

Home Phone

Office Phone

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Mobile Phone

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Home Phone

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Office Phone

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E-Mail

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Who should we contact in case of an Emergency?(*)

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Emergency Contact Phone#(*)

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Dental History

If you have severe pain, or this is an emergency, Please call Dr. Leonhardt immediately!

Office 52 314 137 2462

Mobile 52 314 101 3935

Please select items you wish further information with Dr. Leonhardt

Former Dentist

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Former Dentist Phone #

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Former Dentist Phone E-Mail

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Do you floss?

Yes

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How often do you floss?

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Medical Information

Are you currently under the care of a medical doctor?(*)

Yes

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Why are you seeing the Doctor?

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Medical Doctor's Name

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Doctor's Phone#

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Doctor's E-Mail

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Are you taking any Prescribed or Over-the Counter Medications?(*)

Yes

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