Name
*
Email
*
Today's Date
*
-
Month
-
Day
Year
Address
*
City
*
State
*
Zip
*
Cell #
*
Work Phone #
Home Phone #
*
Preferred method of contact
Email
Call
Physician
Physician's Phone #
Date last exam
-
Month
-
Day
Year
PLEASE INDICATE AND DESCRIBE
Allergic to: Amoxicillin or Penicillin
*
Yes
No
Allergic to: Keflex
*
Yes
No
Allergic to: Latex
*
Yes
No
Allergic to: Clindamycin
*
Yes
No
Allergic to other medications
*
Yes
No
Describe allergic to other medications
*
Intestinal issues
*
Yes
No
Ulcerative Colitis
*
Yes
No
Diverticulitis
*
Yes
No
Adverse reaction to "Novocain" or local anesthetics
*
Yes
No
Describe
*
Fainting Problems
*
Yes
No
Frequency
*
Last episode
*
Breathing problems
*
Yes
No
Sleep Apnea
*
Yes
No
Covid-19
*
Yes
No
Describe
*
Diabetes type 1 or 2
*
Yes
No
Describe
*
Hepatitis
Yes
No
Type
*
When
*
HIV+
*
Yes
No
When diagnosed
*
Abnormal bleeding
*
Yes
No
Describe
*
Dialysis
*
Yes
No
Cancer
Yes
No
Describe
*
Date
*
-
Month
-
Day
Year
Date
Chemo
*
Yes
No
Radiation
*
Yes
No
Where you told to avoid or discuss with your dentist any dental surgery
*
Yes
No
Heart Disease
*
Yes
No
Describe
*
Pacemaker
*
Yes
No
Valve replacement
*
Yes
No
Infectious Endocarditis
*
Yes
No
Heart Attack
*
Yes
No
When
*
Joint replacement
*
Yes
No
Where
*
When
*
Name of Orthopedic Surgeon
*
CURRENT MEDICATIONS
List
Reasons for taking
Are there medical conditions we should be aware of?
*
Yes
No
Describe
Patient/Guardian Signature
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: