Surfaces play a vial role in biology and medicine with most biological reactions occurring at surfaces and interfaces. The foundations, evolution, and impact of biomedical surface science are discussed. In the 19th century, the first observations were made that surfaces control biological reactions. The advancements in surface science instrumentation that have occurred in the past quarter of a century have significantly increased our ability to characterize the surface composition and molecular structure of biomaterials. Similar advancements have occurred in material science and molecular biology. The combination of these advances have allowed the development of the biological model for surface science, where the ultimate goal is to gain a detailed understanding of how the surface properties of a material control the biological reactivity of a cell interacting with that surface. Numerous examples show that the surface properties of a material are directly related to in vitro biological performance such as protein adsorption and cell growth. The challenge is to fully develop the biological model for surface science in the highly complex and interactive in vivo biological environment. Examples of state-of-the-art biomedical surface science studies on surface chemical state imaging, molecular recognition surfaces, adsorbed protein films, and hydrated surfaces are presented. Future directions and opportunities for surface scientists working in biomedical research include exploiting biological knowledge, biomimetics, precision immobilization, self-assembly, nanofabrication, smart surfaces, and control of non-specific reactions.