Dr. Kulaga - New Patient Form - White Wolf Dental

  • Patient Information

    Fill out the form carefully for registration
  • Patient Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • When confirming appointments how do you prefer to be contacted?*
  • Format: (000) 000-0000.

  • Responsible Party

  • Is the patient responsible for this account?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is this Person Currently a Patient in our Office?*
  • For your convenience we offer the following methods of payment. Please check the option you prefer.
  • How did you hear about our office? (Check All That Apply)

  • Medical Health History

    Fill out the form carefully for registration
  • Format: (000) 000-0000.
  • When was your last Dental visit? *
     - -
  • Are you under medical treatment now?*
  • Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?*
  • Are you taking any medication(s) including non-prescription medicine?*
  • Are you currently taking or have you ever taken osteoporosis medications in the past?*
  • Do you use Tobacco?*
  • Do you use controlled substances or recreational drugs?*

  • Are you allergic to any of the following?

  • Local Anesthetics (e.g. novocaine)*
  • Penicillin*
  • Other Antibiotics*
  • Sulfa Drugs*
  • Sedatives*
  • Iodine*
  • Ibuprofen*
  • Tylenol*
  • Codeine*
  • Any Metals (e.g. nickel, mercury, etc.)*
  • Latex Rubber*
  • Other*

  • Do you have or have you had any of the following?

  • High Blood Pressure*
  • Heart Attack*
  • Rheumatic Fever*
  • Swollen Ankles*
  • Fainting*
  • Seizures*
  • Low Blood Pressure*
  • Epilepsy / Convulsions*
  • Cancer*
  • Radiation Therapy*
  • Diabetes*
  • Kidney Diseases*
  • AIDS or HIV infection*
  • Thyroid Problem*
  • Sight Impaired*
  • Hearing Impaired*
  • Heart Disease*
  • Mitral Valve Prolapse*
  • Congestive Heart Failure*
  • Cardiac Pacemaker*
  • Heart Murmur*
  • Frequently Tired*
  • Angina*
  • Anemia*
  • Ephysema / COPD*
  • Tuberculosis*
  • Asthma*
  • Arthritis*
  • Joint Replacement or Implant*
  • Hepatitis / Jaundice*
  • Sexually Transmitted Disease*
  • Stomach Troubles / Ulcers*
  • Vertigo*
  • Neck Pain*
  • Back Pain*
  • Chest Pains*
  • Easily Winded*
  • Stroke*
  • Hay Fever / Allergies*
  • Glaucoma*
  • Recent Weight Loss*
  • Liver Disease*

  • Patient Dental History

  • Date of Last Exam/Cleaning*
     - -
  • Do your gums bleed while brushing or flossing?*
  • Are your teeth sensitive to hot or cold liquids/foods?*
  • Are your teeth sensitive to sweet or sour liquids/foods?*
  • Do you feel pain to any of your teeth?*
  • Do you have any sores or lumps in or near your mouth?*
  • Have you had any head, neck or jaw injuries?*
  • Have you ever experienced any of the following problems in your jaw? (Select ALL thet apply)
  • Do you have frequent headaches?*
  • Do you clench or grind your teeth?*
  • Do you bite your lips or cheeks frequently?*
  • Have you ever had any difficult extractions in the past?*
  • Have you ever had any prolonged bleeding following extractions?*
  • Have you had any orthodontic treatment?*
  • Do you wear dentures or partials?*
  • If yes, date of placement:*
     - -
  • Have you ever received oral hygiene instructions regarding the care of your teeth and gums?*
  • Do you like your smile?*

  • Authorization and Release

  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand
    that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records
    of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I agree
    to be responsible for payment of all service rendered on my behalf of my dependents.

  • Date*
     - -

  • Acknowledgement of Reciept of Notice of Privacy Practice

  • HIPAA

  • I hereby acknowlege that I have received and had an opportunity to ask questions concerning White Wolf Dental Group's Notice of PrivacyPractice.

  • Date*
     - -
  • Should be Empty: