PATIENT INFORMATION
Birth Date:
Last Visit Date:
SPOUSE INFORMATION
PERSON RESPONSIBLE FOR ACCOUNT
Same as Above?YesNo
EMERGENCY CONTACT
DENTAL HISTORY
Are you currently in Pain?
YesNo
Your current Dental Health is:
Toothbrush bristles type:
Do you floss daily?
YesNo
Have you lost any teeth?
YesNo
Toothbrush type:
How long do you use a toothbrush before replacing?
What other oral products do you use?
Do you require antibiotics before dental work? YesNo
Do your gums ever bleed?
YesNo
Have you ever had periodontal disease? YesNo
Does food get caught between your teeth? YesNo
Are your teeth sensitive to hot, cold, other? YesNo
Are you happy with the way your smile looks? YesNo
MEDICAL HISTORY
Do you have a personal physician?YesNo
Last visit date:

Please List Any Allergies

Have you experienced any of the following?

Abdominal Bleeding
YesNo
Frequent or Severe Headaches
YesNo
Radiation Treatment
YesNo
Alcohol Use
YesNo
Glaucoma
YesNo
Rheumatic Fever
YesNo
Anemia
YesNo
Hay Fever
YesNo
Scarlet Fever
YesNo
Arthritis
YesNo
Heart Murmur / Defect
YesNo
Seizures
YesNo
Artificial Bones / Joints
YesNo
Hepatitis
YesNo
Sinus Problems
YesNo
Artificial Valves
YesNo
High Blood Pressure
YesNo
Sleep Apnea Diagnosis
YesNo
Asthma
YesNo
HIV+ / AIDS
YesNo
Snoring
YesNo
Bleeding Disorder
YesNo
Impaired Cognition(difficulty concentrating or thinking) YesNo
Steroid Therapy
YesNo
Blood Transfusion
YesNo
Insomnia
YesNo
Stroke
YesNo
Cancer
YesNo
Ischemic Heart Disease (Coronary Artery Disease/Atherosclerosis) YesNo
Taken: Phen-Phen or Redux
YesNo
Chemotherapy
YesNo
Kidney Problems / Desease
YesNo
Tobacco Use:
YesNo
Colitis
YesNo
Latex allergy
YesNo
Tuberculosis (TB)
YesNo
Congenital Heart Disease
YesNo
Liver Disease
YesNo
Ulcers
YesNo
Daytime Sleepiness / Fatigue
YesNo
Low Blood Pressure
YesNo
Venereal Disease
YesNo
Drug Abuse
YesNo
Mood Disorders / Depression
YesNo
Diabetes
YesNo
Emphysema
YesNo
Osteoporosis
YesNo
Metal Allergy
YesNo
Fainting Spells
YesNo
Pacemaker
YesNo
Difficulty Breathing
YesNo
Fever Blisters / Herpes
YesNo
Persistent Cough
YesNo
Mitral Valve Prolapse
YesNo
Recreational Drug Use
YesNo

For Women:

Are you taking birth control pills?
YesNo
Are you pregnant?
YesNo
Are you nursing?
YesNo

Please list any past surgery/injuries/hospitalizations that are not listed above

Please list any medications that you are taking
If you have a written or typed list you may leave this blank
(Please include regularly used over-the-counter medications and nutritional supplements)

COMMUNICABALE DISEASE CONTROL DISCLAIMER

Our Policy and procedure dictated to us by the Nevada Dental Board of Examiners is as follows: if we during treatment find that there are signs of a communicable disease (i.e. Cold or Flu), we have to delay treatment until medical clearance has been obtained from a licensed physician.

Date:

I affirm that the above information is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes.

I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. I understand that I am responsible for all amounts that my insurance doesn’t cover. Payment is due in full at the time services are rendered unless prior arrangements have been approved.

Date:

Thank you for filling out these forms completely. If you have any questions at any time, please ask us.

Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.