Our Office
▼
Team
▼
Services
▼
Financial Policy
Membership Club
Patient Reviews
Contact
Blog

Skip to content

610.524.9530
Emergency Phone
Monday | Tuesday | Thursday | Friday 8:00 a.m. – 5:00 p.m.
Wednesday: CLOSED
Request an Appointment Make a Payment

Our Office
Team
Services
Financial Policy
Membership Club
Patient Reviews
Contact
Blog

Health Hx Form

Health Hx Form

Health Hx Form

DENTAL HISTORY

Full Name(Required)

First Last

Email(Required)

Phone(Required)

Reason of visit(Required)

Date for last dental visit?

MM slash DD slash YYYY

Date for last dental X-rays?

MM slash DD slash YYYY

Do you have or have you had any of the following? (Please check all that apply)

Bad breath

Grinding teeth

Sensitivity of cold

Bleeding gums

Loose teeth or broken fillings

Sensitivity of hot

Jaw pain / Clicking or popping jaw

Orthodontic treatment

Sensitivity of sweets

Food collection between teeth

Sensitivity when biting

Sores or growth in your month

How often do you floss?

How often do you brush?

MEDICAL HISTORY

Physician Name(Required)

Date for last visit:

MM slash DD slash YYYY

Have you had any serious illnesses or operations?(Required)

Yes

No

(Women) Are you pregnant?(Required)

Yes

No

Describe

Nursing?(Required)

Yes

No

Taking birth control pills?(Required)

Yes

No

Do you have or have you had any of the following? (Please (Please check all that apply)

AIDS

Circulatory Problems

Mitral Valve Prolapse

Rheumatic Fever

Anemia

Congestive Heart Failure

Hemophilia

Shortness of Breath

Arthritis, Rheumatism

Cortisone Treatments

Stroke

Artificial Heart Valves

Cough, Persistent

Hepatitis / Jaundice

Skin Rash

Artificial Joints

Cough up Blood

High Blood Pressure

Swelling of Feet or Ankles

Asthma

Diabetes

HIV Positive

Thyroid Problems

Back Problems

Epilepsy / Seizures

Kidney Disease

Tobacco Habit

Blood Disease

Fainting

Liver Disease

Tonsillitis

Cancer

Headaches / Migraines

Nervous Problems

Tuberculosis

Chemical Dependency

Headaches / Migraines

Pacemaker

Venereal Disease

Chemotherapy

Heart Murmur

Psychiatric Care

Cholesterol

Heart Problems

Radiation Treatment

Respiratory Disease

Is there any health information which was not asked, which you feel may influence your dental treatment?

MEDICAL HISTORY

ALLERGIES

Is there any health information which was not asked, which you feel may influence your dental treatment?

allergies

Asprin

Barbiturates (sleeping pills)

Codeine

Latex

Local Anaesthetics

Penicillin/ Amoxicillin

Sulfa

Other

SIGNATURE

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his / her staff responsible for any errors omissions that I may have made in the completion of this form.

Date for last dental visit?

MM slash DD slash YYYY

Signature(Required)

We Can’t Wait to Meet You!

Fill in the form below and we’ll get back to you ASAP to get you started.

"*" indicates required fields

Name*

First Last

Email*

Phone*

How did you learn about our office?*

Select a service*

How can we help you?
(Please do not include confidential or sensitive information in your message.)

Comments*

CAPTCHA

Testimonials

What Our Client Say

Gary Hill

I needed an emergency repair on my temporary crown, Dr Gross and his team will absolutely amazing, they made me feel at home and very comfortable while getting treated, Dr Gross was good, fast and most importantly he was patient and presently responsive to my request…

Gary Hill

I needed an emergency repair on my temporary crown, Dr Gross and his team will absolutely amazing, they made me feel at home and very comfortable while getting treated, Dr Gross was good, fast and most importantly he was patient and presently responsive to my request…

Your Oral Health is Important to Us

Check out our blog for the latest dental insights and advice!

Dental Emergencies

July 1, 2024

There is never a convenient time to have a dental emergency! No one ever wants…

How To Fix a Broken Tooth So You’re No Longer in Pain

June 1, 2024

The last thing anyone expects at any time is to experience a broken tooth —…

Talking To Your Doctor About Invisalign® Treatment

May 1, 2024

Few of us remember those old days when people only had one or two options…

An Overview of Toothaches

April 1, 2024

Tooth pain and toothaches can occur for various reasons, but the common denominator is that…

Follow Us on Instagram

Your smile is radiant, Kellyann, and we're so happy to have helped you achieve this confidence. Thank you for choosing Chester Springs Dental for your dental cleaning! 🦷🌟
Schedule your consultation, too. ChesterSpringsDental.com

#ChesterSpringsDental #PatientSpotlight #ThankYou

Your smile is radiant, Kellyann, and we're so happy to have helped you achieve this confidence. Thank you for choosing Chester Springs Dental for your dental cleaning! 🦷🌟
Schedule your consultation, too. ChesterSpringsDental.com

#ChesterSpringsDental #PatientSpotlight #ThankYou

Your smile is radiant, Kellyann, and we're so happy to have helped you achieve this confidence. Thank you for choosing Chester Springs Dental for your dental cleaning! 🦷🌟
Schedule your consultation, too. ChesterSpringsDental.com

#ChesterSpringsDental #PatientSpotlight #ThankYou

@chesterspringsdental

•

Your smile is radiant, Kellyann, and we're so happy to have helped you achieve this confidence. Thank you for choosing Chester Springs Dental for your dental cleaning! 🦷🌟 Schedule your consultation, too. ChesterSpringsDental.com #ChesterSpringsDental #PatientSpotlight #ThankYou

21 hours ago

View on Instagram |

1/5

Wow! Look at this smile transformation! This is the difference bonding can make. This procedure can correct chips, cracks, gaps, and discoloration for a brighter, more confident smile. Let’s get you a dream smile too! ChesterSpringsDental.com | Emergency phone: 610.524.9530 #Bonding #Dental #BeforeAndAfter #ChesterSpringsDental

@chesterspringsdental

•

Wow! Look at this smile transformation! This is the difference bonding can make. This procedure can correct chips, cracks, gaps, and discoloration for a brighter, more confident smile. Let’s get you a dream smile too! ChesterSpringsDental.com | Emergency phone: 610.524.9530 #Bonding #Dental #BeforeAndAfter #ChesterSpringsDental

3 days ago

View on Instagram |

2/5

Quality dental care shouldn't be a luxury. At Chester Springs Dental, we offer a range of services and payment options to fit your needs. Learn more at ChesterSpringsDental.com. Emergency phone: 610.524.9530 #AffordableDentistry #ChesterSpringsDental #CompleteDentalCare #Dental #Dentist #Exton

Quality dental care shouldn't be a luxury. At Chester Springs Dental, we offer a range of services and payment options to fit your needs. Learn more at ChesterSpringsDental.com. Emergency phone: 610.524.9530 #AffordableDentistry #ChesterSpringsDental #CompleteDentalCare #Dental #Dentist #Exton

@chesterspringsdental

•

Quality dental care shouldn't be a luxury. At Chester Springs Dental, we offer a range of services and payment options to fit your needs. Learn more at ChesterSpringsDental.com. Emergency phone: 610.524.9530 #AffordableDentistry #ChesterSpringsDental #CompleteDentalCare #Dental #Dentist #Exton

5 days ago

View on Instagram |

3/5

Building healthy smiles for families of all ages! We offer comprehensive dental care for children, teens, and adults at Chester Springs Dental. Schedule your family's appointments today! ChesterSpringsDental.com | Emergency phone: 610.524.9530 #FamilyDentistry #ChesterSpringsDental #HealthySmilesForAll

@chesterspringsdental

•

Building healthy smiles for families of all ages! We offer comprehensive dental care for children, teens, and adults at Chester Springs Dental. Schedule your family's appointments today! ChesterSpringsDental.com | Emergency phone: 610.524.9530 #FamilyDentistry #ChesterSpringsDental #HealthySmilesForAll

7 days ago

View on Instagram |

4/5

Kellyann & Dr. Gross sharing smiles after her dental hygiene appointment! Thanks for choosing us, Kellyann. We're always here to ensure a positive dental experience! 😁✨
Schedule your consultation now at ChesterSpringsDental.com | 610.524.9530
#ThankYou #ChesterSpringsDental #BuildingTrust #DentalHygiene

@chesterspringsdental

•

Kellyann & Dr. Gross sharing smiles after her dental hygiene appointment! Thanks for choosing us, Kellyann. We're always here to ensure a positive dental experience! 😁✨ Schedule your consultation now at ChesterSpringsDental.com | 610.524.9530 #ThankYou #ChesterSpringsDental #BuildingTrust #DentalHygiene

1 week ago

View on Instagram |

5/5

Explore our Payment Options

Become a Member of our In-House Plan Today!

Request an Appointment
Membership Savings Club
Online Forms

610.524.9530
General Questions - Contact Us
New Patients
Schedule an Appointment
601 Gordon Dr, Exton, PA 19341

Office Hours

Monday: 8AM–5PM
Tuesday: 8AM-5PM
Wednesday: CLOSED
Thursday: 8AM-5PM
Friday: 8AM-5PM

Links

Forms
FAQs
Cosmetic Procedures
General and Restorative Procedures
Preventative Procedures
Dental Health

Home
Team
Services
Make a Payment
Membership Club
Patient Reviews
Contact
Blog

Copyright 2024. ChesterSpringsDental.com