• PATIENT INFORMATION

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  • DENTAL HISTORY

  • Do you use tobacco?*
  • Do you consume alcohol?*
  • Do you use cocaine or other recreational drugs?*
  • Are you using contact lenses?*
  • Have you taken any bisphosonates drugs? (ex: actonel, boniva, fosamax)*
  • Do you use an automatic toothbrush?*
  • Do you wear a nightguard?*
  • Is there anything that you would like to change about your smile?*
  • Have you had any difficulty or complications with local anesthesia?*
  • Allergies -- Pick all that apply*

  • HIPAA Notice of Privacy Practice

    Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge reciept of this notice. You may refuse to sign this acknowledgement, if you wish.

    I acknowledge that I have received a copy of this office's Notice of Privacy Practices and have read the contents. I understand that I am giving my consent to use and disclose my health care information to carry out treatment, education, payment activities and health care options

     

  • Date
     - -

  • Medical Information Release

  • Release of Information
    I authorize the release of information including the diagnosis, records; examination rendered to me

  • Messages

  • Please Call*
  • If unable to reach me:*

  • Mark any of the following which you have had or have at present:

  • Cardiovascular*

  • Respiratory*
  • Eyes / Ears / Nose / Throat*
  • Musculoskeletal*
  • Gastrointestinal*
  • Reproductive*
  • Neurological*
  • Endocrinology*
  • Should be Empty: