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Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Financial & Insurance Information
Online Patient Forms
Privacy Policy
Patient Portal
About
About Us
Career Opportunities
Contact
Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Financial & Insurance Information
Online Patient Forms
Privacy Policy
Patient Portal
About
About Us
Career Opportunities
Contact
Call for appiontment
Call For Appointment
Annual Update Form
Annual Update Form
Step
1
of
5
– Patient/Insurance Information
20%
Patient Information
First Name
*
First
Last Name
*
Last
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Marital Status
*
Single
Married
Widowed
Separated
Divorced
Birthdate
*
MM slash DD slash YYYY
Patient Employer
Occupation
Work Phone
How would you like to be notified for upcoming appointments?
Email
Phone
Text
Mobile Carrier (for text message reminder of appointments):
Insurance Information
Any Dental Insurance Coverage?
*
Yes
No
Who is your carrier?
*
Person Responsible for Account
*
Relation to Patient
Birthdate
MM slash DD slash YYYY
Phone
Address (if different from patient's)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please check if you have had any of the following:
Bad breath
Bleeding gums
Clicking or popping jaw
Food collection between teeth
Grinding teeth
Loose teeth or broken fillings
Periodontal Treatment
Sensitivity to hot or cold
Sensitivity to sweets or biting
Sores or growths in your mouth
Frequent headaches
Orthodontic work
Prolonged bleeding following extractions
Pain (joint, ear, side of face)
Other
If you could change something about your smile or teeth, what would it be?
Permission
Emergency Contact
*
Emergency Contact Relation
*
Emergency Contact Phone
*
Patient Medical History
Name of Physician and their specialty:
*
Date of most recent Medical Exam:
MM slash DD slash YYYY
Purpose for medical exam:
*
1. Hospitalization for illness or injury?
*
Yes
No
2. An allergic or bad reaction to any of the following:
*
Aspirin (ibuprofen, acetaminophen, codine)
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Flouride
Chlorhexidine (CHX)
Iodine
Metals (nickle, gold, silver)
Latex
Nuts
Fruit
Milk
Red dye
Other
No Known Allergies
3. Heart problems, or cardiac stent within the last 6 months
*
Yes
No
4. History of infective endocarditis
*
Yes
No
5. Artificial heart valve, repaired heart defect (PFO)
*
Yes
No
6. Pacemaker or implantable defibrillator
*
Yes
No
7. Orthopedic or soft tissure implant (e.g joint replacement, breast implant)
*
Yes
No
8. Heart murmur, rheumatic or scarlet fever
*
Yes
No
9. High or low blood pressure
*
Yes, high blood pressure
Yes, low blood pressure
No
10. A stroke (taking blood thinners)
*
Yes
No
11. Anemia or other blood disorder
*
Yes
No
12. Prolonged bleeding due to a slight cut (or INR > 3.5)
*
Yes
No
13. Pneumonia, emphysema, shortness of breath, sarcoidosis
*
Yes
No
14. Chronic ear infections, tuberculosis, measles, chicken pox
*
Yes
No
15. Breathing problems (e.g asthma, stuffy nose, sinus congestion)
*
Yes
No
16. Sleep problems (e.g sleep apnea, snoring, insomnia, restless sleep, bedwetting)
*
Yes
No
17. Kidney disease
*
Yes
No
18. Liver disease or jaundice
*
Yes
No
19. Vertigo (e.g "the room is spinning")
*
Yes
No
20. Thyroid, parathyroid disease, calcium deficiency
*
Yes
No
21. Hormone dificiency or imbalance (e.g polu cistic ovarian syndrome)
*
Yes
No
22. High cholesterol or taking statin drugs
*
Yes
No
23. Diabetes
*
Yes
No
24. Stomach or deodenal ulcer
*
Yes
No
25. Digestive or eating disorders (e.g ciliac disease, gastric reflux, bulmia, anorexia)
*
Yes
No
26. Osetoporosis/osteopenia or ever taken anti-resorptive medications (bisphosphonatse)
*
Yes
No
27. Arthritis or gout
*
Yes
No
28. Autoimmune disease (e.g rheumatoid arthritis, lupus, scleroderma)
*
Yes
No
29. Glaucoma
*
Yes
No
30. Contact lenses
*
Yes
No
31. Head or neck injuries
*
Yes
No
32. Epilepsy, convulsions (seizures)
*
Yes
No
33. Neurologic disorders (e.g alzheimer's disease, dementia, prion disease)
*
Yes
No
34. Viral infections and cold sores
*
Yes
No
35. Any lumps or swelling in the mouth
*
Yes
No
36. Hives, skin rash, hay fever
*
Yes
No
37. STI/STD/HPV
*
Yes
No
38. Hepatitis
*
Yes
No
39. HIV/AIDS
*
Yes
No
40. Tumor, abnormal growth
*
Yes
No
41. Radiation therapy
*
Yes
No
42. Chemotherapy, immunosuppressive meds
*
Yes
No
43. Emotional difficulties
*
Yes
No
44. Psychiatric treatment or antidepressant medication
*
Yes
No
45. Concentration problems or ADD/ADHD
*
Yes
No
46. Alcohol/Recreational drug use
*
Yes
No
Are you:
47. Presently being treated for any other illness
*
Yes
No
48. Aware of a change in your health in the last 24 hours (fever, chills, new cough, diarrhea)
*
Yes
No
49. Taking medications for weight management
*
Yes
No
50. Taking dietary supplments, vitamins, and/or probiotics
*
Yes
No
51. Often exhausted or fatigued
*
Yes
No
52. Experiencing headaches or chronic pain
*
Yes
No
53. A smoker, smoked previously or other (smokless tobacco, vaping, e-cig, or cannabis)
*
Yes
No
54. Considered a touchy/sensitive person
*
Yes
No
55. Often unhappy or depressed
*
Yes
No
56. Taking birth control pills
*
Yes
No
57. Currently pregnant
*
Yes
No
58. Diagnosed with a prostate disorder
*
Yes
No
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:
List all medications, supplements, vitamins, and/or probiotics you're currently taking:
Authorization
Consent
I agree to the below statement.
I consent to allow photographs and/or x-rays to be used for demonstrations, marketing material, patient education, etc.
Consent
*
I agree to the below statement.
I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions.
Consent
*
I agree to the below statement.
I have answered all questions regarding myself, or my dependent’s medical history and present health condition fully and truthfully, including allergies. I also understand if there are any changes in my, or my dependents health I am to inform the doctor at my next appointment.
Consent
*
I agree to the below statement.
I agree to provide a minimum of 24 hour notice if I need to change my appointment for any reason. I understand if I fail an appointment I may be charged a fee. Failure to show for a second appointment may result in dismissal from the practice.
Consent
*
I agree to the below statement.
I instruct the dentist to deliver care that, in their professional judgement, is necessary in the restoration of my health once they’ve been discovered and discussed.
Consent
*
I agree to the below statement.
State and federal laws require us to maintain the privacy or your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. This form is available online for your convenience, if you prefer a paper copy, please feel free to contact us.
Full Name
*
Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.
Date
*
MM slash DD slash YYYY
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