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About Us
Immediate Implants
Procedures
Gingival Grafting
Bone Grafting
Tooth Extraction
Tooth Maintenance
Tour Our Office
New Patients
Book Appointment
New Patients
Book Appointment
PATIENT INTAKE FORM
Patient Registration:
Date
Phone
Email
First Name
Last Name
Middle Initial
Street Address
City
State
Zip
Age
Sex
Male
Female
Birthdate
Status
Single
Married
Separated
Divorced
Widowed
Minor
Occupation
Employer/School
Employer/School Address
Employer/School Phone
Spouse/Gardian Name
Spouse/Gardian Birthdate
Spouse/Gardian Employer
Spouse/Gardian Occupation
Spouse/Gardian Employer Address
Spouse/Gardian Employer Address
Who Is responsible For Account?
Relationship To Patient
Your Social Security #
Spouse/Parent Social Security #
Name Of Dental Insurance
Group Number
Emergency Contact Name
Emergency Contact Phone
Who should we thank for referring you?
Medical History:
Physician's Name
Date Of Last Physical
Have you ever had any of the following? (Check Boxes that Apply):
Have you had any of the following?
Allergies
Epilepsy
Pacemaker
Arthritis
Headaches
Psychiatric Care
Artificial Heart Valves or Joints, Screws, etc.
Heart Murmur
Radiation Treatment
Back Problems
Heart Problems
Recent Weight Loss
Bleeding Abnormally
Hemophilia
Respiratory Disease
Blood Diseases
Hepatatits, Jaundice or Liver Disease
Rheumatic Fever
Cancer
Hernia Repair
Sinus Problems
Chemical dependency
High Blood Pressure
Special Diet
Chronic Diarrhea
HIV/AIDS
Stroke
Circulatory Problems
Low Blood Pressure
Swollen Neck Glands
Congenital Heart Lesions
Mitral Valve Prolapse
Ulcer
Diabetes
Nervous Issues
Venereal Disease
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time? If so what?
Do you have any drug allergies or have you ever had an adverse reaction to any medication or anesthesia?
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimen, Adipex, Fasti (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine).
Drugs? Y/N
Yes
No
Are you under the care of a physician?
Physician? Y/N
Yes
No
For what conditions?
If patient is a child, what is his/her weight?
(Women) Do you suspect that you are pregnant?
Are You Pregnant? Y/N
Yes
No
Due Date?
(Women) Are you nursing?
Are You Nursing? Y/N
Yes
No
(Women) Taking birth control pills?
Taking birth control pills? Y/N
Yes
No
Is there anything else we should know about your medical history?
Submit Form
PATIENT INTAKE FORM
Patient Registration:
Date
Phone
Email
First Name
Last Name
Middle Initial
Street Address
City
State
Zip
Age
Sex
Male
Female
Birthdate
Status
Single
Married
Separated
Divorced
Widowed
Minor
Occupation
Employer/School
Employer/School Address
Employer/School Phone
Spouse/Gardian Name
Spouse/Gardian Birthdate
Spouse/Gardian Employer
Spouse/Gardian Occupation
Spouse/Gardian Employer Address
Spouse/Gardian Employer Address
Who Is responsible For Account?
Relationship To Patient
Your Social Security #
Spouse/Parent Social Security #
Name Of Dental Insurance
Group Number
Emergency Contact Name
Emergency Contact Phone
Who should we thank for referring you?
Medical History:
Physician's Name
Date Of Last Physical
Have you ever had any of the following? (Check Boxes that Apply):
Have you had any of the following?
Allergies
Epilepsy
Pacemaker
Arthritis
Headaches
Psychiatric Care
Artificial Heart Valves or Joints, Screws, etc.
Heart Murmur
Radiation Treatment
Back Problems
Heart Problems
Recent Weight Loss
Bleeding Abnormally
Hemophilia
Respiratory Disease
Blood Diseases
Hepatatits, Jaundice or Liver Disease
Rheumatic Fever
Cancer
Hernia Repair
Sinus Problems
Chemical dependency
High Blood Pressure
Special Diet
Chronic Diarrhea
HIV/AIDS
Stroke
Circulatory Problems
Low Blood Pressure
Swollen Neck Glands
Congenital Heart Lesions
Mitral Valve Prolapse
Ulcer
Diabetes
Nervous Issues
Venereal Disease
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time? If so what?
Do you have any drug allergies or have you ever had an adverse reaction to any medication or anesthesia?
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimen, Adipex, Fasti (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine).
Drugs? Y/N
Yes
No
Are you under the care of a physician?
Physician? Y/N
Yes
No
For what conditions?
If patient is a child, what is his/her weight?
(Women) Do you suspect that you are pregnant?
Are You Pregnant? Y/N
Yes
No
Due Date?
(Women) Are you nursing?
Are You Nursing? Y/N
Yes
No
(Women) Taking birth control pills?
Taking birth control pills? Y/N
Yes
No
Is there anything else we should know about your medical history?
Submit Form
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Home
About
Immediate Implants
Procedures
TOUR
New Patients
Book Appointment
