Medical and Dental History Intake Form

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Primary Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Preferred Pharmacy Name

Preferred Pharmacy Phone Number

Format: (000) 000-0000.

Preferred Pharmacy Address

YesNo

Please list other current medications you are taking. Include name of medicine, reason, dosage, how many times/day, last time taken (prior to surgery):

If yes to Diabetes, please provide current A1C and date of last A1C test:

YesNo

If Yes, Date started using (mm/dd/yyyy):

Date

Date of Birth (mm/dd/yyyy)*

Age*

Height (inches)

Weight (lbs)

MaleFemaleOtherPrefer Not to Say

Date of last physical exam

Physician's Name

Physician's Phone

Format: (000) 000-0000.

YesNo

Medical and Dental History Intake Form

Patient Information

Preferred Pharmacy

Quick Reference Section

Medical Background

Women’s Health

Allergies

Medical History

Last Dental Visit

Dental History

Facial/Jaw Pain

Orthodontic

Sleep/Airway Issues

Consent for Treatment