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Tell us about yourself.



We need this information to ensure your safety and health and the best possible dental care for you. All information is kept
confidential among only our staff, your emergency contacts, and, if necessary, your doctor.

Please fill in the fields below and click "submit".


               

Name:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Date of Birth:
Address (include city + postal code):




Whom may we thank for referring you?
 
 
   In case of emergency call:
Responsibility for your account           

Name:
Relationship:
Home Phone:
Work Phone:
Cell Phone:
Do you have dental insurance?
(Please bring this information with you to the office)
Where you work:
Name of person responsible for your account, if not yourself:
Relationship:
 
 
Yes
No
Your medical history           
1. Are you presently under the care of a physician?
Reason:
2. Are you currently taking any medications?
Please list:
3. Have you been hospitalized in the last 5 years?
Reason:
4. Have you ever been prescribed antibiotic coverage before a dental appointment?
5. Are you allergic to any medications?
Please list:
6. Do you smoke? If yes, how many per day?
7. (Women) Are you pregnant or suspect you might be?
8. (Women) Are you taking birth control pills?
9. (Women) Are you taking supplementary hormones?
 
 
   Check all that apply to your medical history
     
 
 
Your physician's name and city:
   Your dental history
Check all that apply to your dental history           
Date of last dental visit:
Treatment you received:
Date of last X-rays:
How often do you brush?:
How often do you floss?:
Do you use other hygiene aids?:
 
 
Your bite
Yes
No
Do you grind or clench your teeth?
Have you noticed chipped or worn edges on your teeth?
Has a dentist adjusted the way your teeth fit together?
Do you awaken with headaches?
Is it difficult to open or close your jaw?
Do you hear clicking/popping sounds when chewing?
 
 
Your gums
Yes
No
Are your gums swollen or tender?
Do you experience bad breath?
Do your gums bleed when you eat, brush, or floss?
Are there any sore spots in your mouth?
Are you aware of any loose teeth?
Are any teeth sensitive to heat, cold, sweets, pressure?
 
 
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Your Submission of this form
 

By submitting this form you agree that you:

  • have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information
  • have had the opportunity to ask questions and receive answers about your medical-dental history
  • authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care
  • understand that consultation with your medical doctor may be required, and you consent to your physician being contacted if necessary
  • understand that responsibility for payment for the dental services provided for you or your dependents is yours, and you will assume responsibility for fees associated with these services.
 
 
 
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