Patient General Information
*First Name:
*Last Name:
*Address:
*City:
*Zip:
*Main Phone:
*Email:
Dental History
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Grind or clench teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Requires premedication?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Tuberculosis/Lung Disease
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Hemophilia
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
History of Bisphosphonates
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Latex/Metal Allergy
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Asthma
No
Yes
Nervous Disorders
No
Yes
Treated for Emotional Problems
No
Yes
FEMALES: Are you pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
Father/Guardian 1 Name:
Responsible for Payment
No
Yes
Responsible for Insurance
No
Yes
Father/Guardian 1 Email:
Mother/Guardian 2 Name:
Responsible for Payment
No
Yes
Responsible for Insurance
No
Yes
Mother/Guardian 2 Email: