• Patient Contact Information

    The following information is requested to assist the Doctor in administering the proper dental service.
    Please answer the questions to the best of your ability.

    Thank you for your cooperation.

  • Date
     - -
  •  -
  •  -
  •  -
  • Best way to contact you (please mark)
  • If Cell phone
  • Preferred way to confirm appointment
  • If cell Phone
  • Date of Birth
     - -
  • Sex
  • Marital Status

  • Emergency Contact Information

  • Format: (000) 000-0000.
  •  -
  • Dental Insurance
  •  -

  • MEDICAL  HISTORY

  • General heath (Please mark)
  • Are you presently under the care of a physician?
  • Are you taking any medication now?
  • Are you allergic to :
  • Rows
  • Do you smoke cigarettes?
  • Is your blood pressure :

  • WOMEN 

  • Are you pregnant?
  • Do you experience premenstrual syndrome?

  • Do you have or have you ever been informed that you had any of the following :

  • Rows
  • Rows
  • Rows

  • DENTAL HEALTH

  • When was your last dental visit?
     - -
  • Do you use mouth wash
  • Have you ever had any serious problems associated with previous dental treatment?
  • Rows
  • Are you apprehensive (nervous) about your dental treatment?
  • If yes — have you had
  • What texture brush do you use?
  • Do you wear full dentures?
  • If yes ? which one
  • Do you wear partial dentures?
  • If yes ? which one

  • CONSENT:

    The undersigned hereby authorizes the Doctor to perform all the necessary diagnostic procedures deemed appropriate to make a thorough diagnosis of the patients' dental or oral-facial needs including x-rays, study models, photographs, medications, and the use of local anesthetic agents.

  • Date*
     - -
  • Should be Empty: