Adult Health History Form

To learn more about what makes our team and practice so unique, or to schedule your first appointment, get in touch with Pittsford Family Dental and a member of our staff will be happy to get you started.

We can be reached by phone at 585-248-5250 or via email through our contact page.

Have you ever had any of these conditions?

Are you allergic to or have you ever had an adverse reaction to any of the following?

Do you currently have or have ever had any of the following?

Please answer yes or no to the following: