First Name (required)
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Last Name (required)
Birth Date (DOB) (required)
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Your Email (required)
Emergency Contact Name
Emergency Contact Number
How did you hear about us (check)
WebsiteGoogle SearchFacebookPrint AdvertisingWalk ByPersonal Referral
Friend/Family Referral (name)
Insurance Company #1
Policy Holder's Name
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Insurance Company #2
1. Are you currently in good health?
If no, please explain:
2. Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)?
If yes, please list:
3. Do you currently Smoke?
If yes, for how long?
4. Are you allergic to or ever had a reaction to any of the following:
PenicillinCodeineLocal Anesthetic ("freezing")Aspirin (ASA)Sulfa Drugs
5. Are you under the regular care of a physician?
If yes, please explain:
6. Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal?
7. Have you ever had a serious illness or operation?
8. Do you currently have or ever had any of the following conditions?
Heart Trouble or StrokeHeart MurmurThyroid DisorderRheumatic FeverBreathing ProblemsArthritisHIV PositiveTumors or CancerHigh/Low Blood PressureHepatitisLiver DiseaseKidney DiseaseMental IllnessDiabetesTuberculosesEpilepsy or SeizureBlood DisordersHormonal Disorder
Other conditions to note:
9. Women: Are you pregnant?
If yes, which Trimester?
10. Is there anything else we should know about your health?
If yes, please explain:
11. What dental condition(s) concern you at present?
12. What is the name and contact info for your previous dentist?
13. Were X-rays taken at your last dental visit>
14. What do you want for your teeth over the next 20 years?
15. Have you noticed any signs of the following:
Bleeding GumsDrifting of TeethGum AcheReceding GumsLoose Teeth
16. Do you have any clicking, popping or pain in your jaw joint?
17. Are you aware of clenching or grinding your teeth?
18. Do you have any missing teeth that you feel should be replaced?
19. Would you like to improve the appearance of your teeth?
20. Do you floss your teeth>
21. Have you had any complications or difficulty with previous dental treatment?
22. How do you rate yourself as a dental patient?
CalmSlightly NervousVery Anxious
I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I will assume responsibility for fees associated with those procedures.
Important Note: The SUBMIT Button will allow you to click it when all the required fields in the form are completed. If you're reached this part of the page and the SUBMIT button won't let you click it, please scroll up the page to fill the required spaces.
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