DENTAL ANESTHESIA SERVICES OF LOUISIANA
Adult Online Registration Form
General Information
Patient's Initials
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Age
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Gender
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Year
Best Contact Number
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-
Area Code
Phone Number
Dentist
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Boyd Family Dental- Drs Jared Boyd, McKenzy Boyd
Ronald Hermes DDS
Dr Shane McPherson
Smile Dental Center- Dr Pary
Bossier Endodontics- Dr Turner
Dr William Borders and Dr Blaine Calhan
Dr Jack O'Neill
Dr Robert Guier
Sterling Dental Center
Cormier Family Dentistry-Drs Adam and Jana Cormier
Eddleman Family Dentistry- Drs Eddleman
Gilmer Endodontics-Dr John Gilmer
Lake District Family District- Drs Carlton, Richter, Mangum
House Family Dentistry- Dr Ike House, Dr Brittany House, Dr Reuben House
Family Dentistry- Dr Gaensehals and Boyd
Dr Patrick McGee
Lott Family Dentistry- Dr Lott
Shreveport Bossier Family Dental- Drs Dies, Ben Beach, Katie Beach,Haydel, Cotton, Hastings, Tate, Patton, Nguyen
Medical History
Weight
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Height
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Any past surgeries ? If so any problems with anesthesia?
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Has anyone in the your family had a reaction to anesthesia?
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Yes
No
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
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Are you allergic to any medication? What type of reaction?
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Let's get a current picture of your health
Health History
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No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Stroke, seizure, other neurologic problem
High blood pressure, heart failure, chest pain, irregular heart beat
Asthma, TB, sleep apnea, snoring, recent cold or cough
Hepatitis, bleeding problem, liver problems
Hiatal hernia, ulcers, frequent heart burn
Diabetes or low blood sugar
Problem with kidneys
Additional medical information not listed above
Type a question
I have read the pre and postprocedure instructions and cancelation policy( located on forms page), fully understand them and agree to their terms (please sign with your cursor below).
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