• Welcome to Lotus Smile Dental

  • 欢迎光临康嘉牙医诊所

  • Please read this information before you continue(请确认您已阅读以下条款)*

  • PERSONAL INFORMATION 个人信息

  • Date of Birth 出生日期*
     - -
  • Gender 性别*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have dental coverage? 您是否有有牙医保险?

  • DENTAL HISTORY 牙医历史

  • Format: (000) 000-0000.
  • Do you have sensitivity to temperature or pressure? 您是否有牙齿冷热敏感?*
  • Do your gums bleed when you brush your teeth? 您是否每次刷牙的时候出现牙龈出血?*
  • Do you grind/clench your teeth? 您是否出现夜间磨牙的情况?*
  • Do you have any cracking or clicking of your jaw? 您是否下颌关节有响声?*

  • MEDICAL HISTORY 医疗历史

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you allergic to any medication? 您是否有对药物过敏?*
  • If you are allergic to some medication, please specify the details(If not select NA): 如果有药物过敏的情况, 请说明是哪些药物:(如果没有药物过敏请选择NA)*
  • Are you taking any medication? 您是否有在吃的药物?*
  • Do you have a history of a major illness? 您是否有重大的疾病或受伤历史?*
  • For female: Are you pregnant? 如果您是女性, 请问您是否怀孕?*
  • Select any of the medical conditions below that you have had or currently have: 请标注您的身体是否有如下的情况:*

  • *This is to certify that I, the undersigned, consent to the performing of the dental and oral procedures agreed to be necessary or advisable, including the use of general or local anesthetic as indicated and I will assume responsibility for fees associated with those procedures. In the presence of insurance, I authorize the handling of my insurance and exchange of information whether electronically or manually by Lotus Smile Dental office. Our office policy is 48 hours notice to cancel/change an appointment. $60 will be charged for late cancellation or no show.

    Following is the Chinese Version:

    以下是中文版本:

    * 我尽所能提供我精确及完全的医学及牙医病史，并予授权我的医生给牙医诊所我的病史及所需医学报告。我授权牙医诊所医师及洗牙师给我本人及本人之未成年子女实施局部麻醉或处方药物。如果取消我会给诊所48小时的通知时间，如果没有及时通知我会承担$60的预约未到的费用。

  • Date 日期
     - -
  • Should be Empty: