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Patient Info Form

Name(Required)
Address(Required)



Medical History

Have you been under the care of a physician during the last 2 years?(Required)
Have you had any serious illness or operations?(Required)
Have you ever been diagnosed with cancer?(Required)
Have you had abnormal bleeding with surgery or trauma(Required)
Are you allergic or have you reacted adversely to any of the following: (please check all that apply)
Do you currently smoke?(Required)
Have you ever smoked?(Required)
Can you climb 2 flights of stairs without chest pain/shortness of breath?(Required)

Do any of these medical conditions apply to you?
Cardiovascular
Neurological
Endocrine
Hematology
GU
Respiratory
Gastrointestinal
Infections
MSK
For women, are you pregnant?

Dental History

Are you experiencing any discomfort at this time?(Required)
Do you clench or grind your teeth?(Required)
Have you had an anxious experience with any previous dental treatment?(Required)
How often do you brush your teeth per day?(Required)
Do you use dental floss?(Required)
Do you use toothpicks?(Required)
Do you use mouthwash?(Required)
Did you have your teeth cleaned?(Required)
Do you currently experience any of the following?
Have you had any of the following?

I understand that it is my responsibility to inform this office of any changes in my medical status. I also accept full responsibility for payment on my account regardless of any third party insurance involvement.
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