* Today's Date
* Patient's Name
* Phone Number
Parent or other Emergency Contact
* Parent or other Emergency Contact
Dental Insurance Company
This may be a different company than your medical insurance.
Subscriber or Member ID Number
This may be the subscriber's social security number if you did not receive an insurance card.
How did you hear about our office?
If online please let us know which site (Google, Facebook etc.)
Name of Primary Care Physician
Name of Medical Specialist
If you see one
Please list any medications (prescriptions, vitamins or supplements)
Please list any allergies
Please list any hospitalizations, surgeries or other significant injury/illness
Do you use tobacco products?
Do you drink alcohol or use recreational drugs?
If yes, how often
For the following questions you only need to click if the answer is yes. Please provide details at the end of the section for any positive responses.
If yes to any of the above or other medical problems we should know about, please explain below
Are you pregnant, possibly pregnant or planning pregnancy?
If yes, how many weeks
Any particular concerns for your teeth?
Any history of cavities, traumatic injuries or other dental problems?
Have you ever undergone orthodontic treatment?
If yes, please describe and list name of treating orthodontist
If yes, please explain
Is there anything else we should know before treating you?
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