Initial Visit Patient Forms (MDR)

Medical and Dental History
Full Name

First NameLast Name
What is your Gender?

FemaleMale
Date of birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check the medical conditions that apply to you

AsthmaCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyAnemiaHepatitisHIV/AIDSPacemakerKidney diseaseLiver diseaseMitral valve prolapseStrokeJoint replacementShortness of breathRespiratory diseaseDrug dependencyOther
Have you ever been told by your physician that you require premedication before dental hygiene appointments?

YesNo
Women only, Are you pregnant?

YesNo
Are you currently taking any medication?

YesNo
If yes, please list:
Do you have any allergies?

YesNo
If yes, please list:
Have you had any surgeries in the past?

YesNo
If yes, please list:
Are you a smoker?

YesNo
Are any of your teeth sensitive to (Select all that applies):

SweetsColdHotBiting or chewing
Do you have or notice any of the following (Select all that applies):

Biting your lips or cheeks oftenMouth breathingClicking or popping of the jawJaw painSleeping disorderGrinding or clenching of your teethBad breathBad/metallic taste in your mouthBleeding gumsFood getting stuck between your teeth oftenCold sores oftenLoose teethDifficulty chewingDifficulty opening or closing mouth
Have you ever had (Select all that applies):

Periodontal (gum) surgeryOrthodontic treatment (braces)Night guardSports guard
How happy are you with your smile?
Do you have any dental concerns?
Have you ever had any bad dental experiences or dental complications?

How nervous are you about dental hygiene visits?

	1	2	3	4	5

1 is Not nervous at all, 5 is Very nervous

When was your last dental visit?
How often are you brushing?
How often are you flossing?
How did you hear about Flossophie?
Do you have dental insurance?

YesNo
Upload Insurance Card (Front and Back)

Browse Files

Cancelof
Waivers under HIPAA.

(a) Patient acknowledges that while we try our best to use secure channels, we cannot guarantee that communications with Flossophie Dental Hygiene using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Flossophie Dental Hygiene's obligations to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by our office.

(b) By providing Patient’s e-mail address to us, Patient authorizes Flossophie Dental Hygiene to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following:
1. E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
2. Although we will make all reasonable efforts to keep e-mail communications confidential and secure, we cannot guarantee the absolute confidentiality of such e-mail communications.
(c) Patient understands that before and after photos may be taken to be used for the purpose of marketing on social media.
Patient Initials:*
Patient acknowledges and agrees that Flossophie Dental Hygiene, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected.
Patient Name*
Today's Date*

MonthDayYear

Medical and Dental History