Today's Date* (YYYY-MM-DD) First Name* Last Name* Gender MaleFemaleOther Address City Postal Code Birth Date (YYYY-MM-DD) Email Home Phone Cell Phone Allow SMSYesNo Place of Employment Work Phone Emergency Contact not living with you Phone
Name of Physician Phone Address of Physician Date of last Physical Exam(YYYY-MM-DD)
Are your teeth experiencing any discomfort or pain at this time? YesNo If Yes then explain
Do you frequently get food caught between any teeth? Where? YesNo If Yes then explain
Are you interested in Teeth WhiteningStraightening of Teeth (Invisalign)Smile transformation
Please select if you have or have you had any of the following ClenchingGrindingJaw PainPopping SoundsLimited OpeningLockingSensitivity
Are you in good general health? YesNo List ALL Medical Conditions and Allergies Please list ALL current medications, dosage and reason for usage Have you been hospitalized or had any serious illness or operation ever? YesNo If yes then When and What Have you tested positive for COVID-19? If Yes, what was the date you tested positive?YesNo Where? Please select if you have had an allergic reaction or reacted to any of the following Local anaestheticsAntibioticsPenicillinSulfa drugsBarbituratesSedativesAspirinTylenolSleeping PillsCodeineDemerolLatex (eg. rubber gloves) Please select if you have had any of the following Cardiac PacemakerTuberculosisSinusitisEmphysemaChronic BronchitisAsthmaSinus troubleStomach ulcersHepatitisHIVJaundiceDiabetesThyroid troubleAnemiaSickle Cell diseaseBlood disordersHemophiliaGlaucoma Do you have chest pain after exercise? YesNo Please select if have ever had EpilepsyFainting SpellsSeizuresEmotional disturbance Are you currently under physician’s care for anything? YesNo Is there any family history of blood disorders? YesNo Have you had abnormal bleeding after any surgery, extraction or trauma?YesNo Have you ever had a blood transfusion? When? YesNo Please select if you have or have you ever had? ArthritisInflammatory RheumatismBone InfectionOsteoporosisKidney troubleVenereal diseaseExposure to HIV virusAIDSTumorChemotherapyRadiation therapyCancer Do you have artificial joints? What and date of placement: YesNo If Yes. Do you smoke or use tobacco? YesNo If Yes. How many times per day? Do you drink alcohol? YesNo If Yes. How much in a week? Do you consume any recreational substances? YesNo If Yes. What and how often? Are you pregnant or nursing? YesNo If Yes. How many weeks?
Is there anything in your medical and dental history that we have not specifically asked about that we should be made aware of? If so, please explain.
I hereby authorize and request the performance of dental services for myself or any of my dependents. I also give my consent to the advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for dental treatment or diagnostic purposes. These records may include study models, photographs, or x-rays. I understand and acknowledge that I am financially responsible for the services provided for myself or any of my dependents, regardless of the insurance coverage. I also understand that the treatment estimate presented to me is only an estimate and occasionally, the need may arise to modify treatment. I believe the information given in the previous pages of the medical and dental history to be true to the best of my knowledge.
Full Name* Date (MM-DD-YYYY)*
Your Signature*
