Planetsmiles
Name
Prefix
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Ph:
Format: (000) 000-0000.
Mobile Ph:
Format: (000) 000-0000.
Work Ph:
Format: (000) 000-0000.
Email:
example@example.com
Date of Birth:
-
Day
-
Month
Year
Date
Occupation:
Employer:
What are your main concerns?
When was your last Dentät visit?
Confidential Medical History: Are you, or have you ever been treated for any of the following?
Type a question
Rows
Yes
No
Rheumatic Fever
Artificial Heart Valve
Blood disorders
Hepatitis B
Hepatitis C
HIV/Aids
Heart Disease
Diabetes
High Blood Pressure
Pacemaker
Cancer
Tumour
Epilepsy
Strokie
Asthma
Arthritis
Heart Murmur
Are you pregnant
Any other conditions?
Allergies Y/N
(Please List):
Y/N
(Please List):
Doctors Name:
Telephone:
Format: (000) 000-0000.
Emergency Contact Name:
Relationship:
Home Ph:
Format: (000) 000-0000.
Mobile Ph:
Format: (000) 000-0000.
Work Ph:
Format: (000) 000-0000.
Name of Healthcare Fund:
Membership Number:
Medicare Number:
Position:
Who is responsible for your account?
How would you rate your anxiety levels when visiting the Dentist on a scale of 1 - 10 (1 being the most relaxed and 10 being the most anxious)?
How did you find Us? (Please Tick)
Doctor
Dentist
Internet
Phone Book
Friend
Signature:
Date:
-
Day
-
Month
Year
Date
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