Lynn Haven Dental Specialists Patient Intake Form

1
Name* This field is required.
First Name
Last Name
2
Take Photo Of the Front of Your Drivers License (Or Skip to Upload Photo As a File)
3
Upload Photo Of the Front of Your Drivers License - Disregard if You Took Photo In Previous Step
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
4
Gender* This field is required.
Male
Female
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Social Security Number
7
Marital Status
Single
Married
Divorced
Seperated
Widowed
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Mobile Phone Number* This field is required.
Please enter a valid phone number.
10
Home Phone Number - Optional
Please enter a valid phone number.
11
Email* This field is required.
example@example.com
12
Responsible Party if Other Than Patient
First Name
Last Name
13
Responsible Party's Relationship to Patient
14
Emergency Contact Person
First Name
Last Name
15
Emergency Contact Person Phone
Please enter a valid phone number.
16
Emergency Contact Relationship to Patient
17
How Did You Hear About Us?* This field is required.
Google
Facebook
Word of Mouth
Bing
Other
Yahoo
TV
Radio
Instagram
Tik Tok
NextDoor
Other Dentist/Doctor
In-Office Referral
18
Your Physician's Name
First Name
Last Name
19
Your Physician's Phone Number
Please enter a valid phone number.
20
Are You Currently Undergoing Medical Treatment? * This field is required.
YESNO
21
If You Answered Yes, Please Explain Any Current Medical Treatment
22
Do You Need Premedication for Any Dental Treatment?* This field is required.
YESNO
23
Are You Currently Taking Any Medications?* This field is required.
YESNO
24
If You Answered Yes, Please List Any Current Medications You are Taking
25
Name of Pharmacy
26
Your Pharmacy's Phone Number
Please enter a valid phone number.
27
Are You Currently Taking Weight Loss Medications such as Ozempic or Tirzepatide?* This field is required.
YESNO
28
Are You Currently Taking Blood-Thinners?* This field is required.
YESNO
29
If You Answered Yes, Please List Names of Blood-Thinners You are Taking
30
Have You Taking any Medication for Osteoporosis to Improve Your Bone Density?* This field is required.
YESNO
31
If You Answered Yes, Please Explain How the Bone Density Medicine Was Taken
32
Do You Experience any Form of Dry Mouth?* This field is required.
YESNO
33
If Yes, Is Your Dry Mouth?
Mild
Moderate
Severe
34
Do You Use Tobacco? * This field is required.
YESNO
35
Do You Use Controlled Substances? * This field is required.
YESNO
36
If Female, Are You Pregnant or Nursing?
YESNO
37
Do you Take Oral Contraceptives?
YESNO
38
Do you Take Aspirin? * This field is required.
YESNO
39
Do you Use or Sleep with Supplemental Oxygen? * This field is required.(i.e., CPAP Machine)
YESNO
40
What is the Main Concern or Purpose of Your Visit?* This field is required.
41
Date of Last Teeth Cleaning
Date
Year
Month
Day
42
Name of Dentist
43
Please Explain Any Other Information We Should Know About Your Dental Health
Huge
Large
Normal
Small
Ok
Ok
44
Are You Allergic to Any of the Following Medications?* This field is required.
Aspirin
Penicillin
Iodine
Dental Anesthetics
Sedatives
Jewelry
Codeine
Tetracycline
Latex
Erythromycin
Metals
Other
None
45
Do You have any Other Known Allergies? If yes, please indicate and explain it below:
46
Patient Medical History* This field is required.(Check box if condition applies to you or has applied to you in the past)
high blood pressure
low blood pressure
cardiac pacemaker
heart attack
heart murmur
stroke
rheumatic fever
heart surgery
heart disease
mitral valve prolapse
fainting spells
easily winded
frequently tired
chest pains
seizures
anemia
recent weight loss
asthma
emphysema
respiratory problems /snore
hay fever
cancer/chemotherapy/radiation
epilepsy
arthritis
glaucoma
joint replacement
swollen ankles
diabetes
HEP-A
HEP-B
HEP-C
kidney problems
jaundice
sinus problems
headaches or migraines
HIV / AIDS
sexually transmitteddiseases
ulcers
tuberculosis
None
Other
47
If you are diabetic, what was your last A1c, and what were the results/readings?
48
Do You Have Any Other Medical Conditions that the Clinic Should be Aware of? If yes, please indicate and explain it below:
49
I understand that this procedure cannot guarantee 100% expeted results.

I understand that post-operative care are needed in order to fully achieve the goal. I confirm that it is my responsibility to follow the treatments and follow-ups after the procedure.

I permit the clinic to take photographs and videos of the procedure for educational purposes only.

I allow this clinic to use my photographs for "before and after results" for marketing and advertising purposes.

I hereby release this clinic for any indemnification or hold them harmless agains physical damage, personal injury, or accidents that might happen during and after the procedure.

I confirm that all information I provided in this form is accurate and true.
50
Patient Signature* This field is required.
Powered by Jotform SignClear
51
Date Signed* This field is required.
Date
Month
Day
Year
Should be Empty: