We don’t like the forms either, but sometimes you have to eat your vegetables… Name * First Name Last Name Date of Birth Do you have any dependents? Include their names and dates of birth Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Email * Dental Insurer Leave Blank if Not Insured Subscriber ID or Member ID Leave Blank if Not Insured Do you have any secondary dental insurance? Leave Blank if Not Name of Prior Dentist * Date of Last Dental Visit * Give us your best guess MM DD YYYY How frequently do you brush your teeth? * Twice a day Once a day Occasionally Rarely How frequently do you floss? * Daily Weekly Occasionally Rarely Never Any of these conditions apply? Bad Breath Bleeding Gums Broken Fillings Clicking Jaw Grinding Teeth Facial Pain Sores in the Mouth Any other concerns we should know about? Are you allergic to any of these? Aspirin Codeine Latex Local Anathesia Penicilin Sulfa Any other allergies we should know about? Do you use any of these substances? Alcohol Tobacco High Sugar Intake Check all the health conditions that apply... Blood pressure AIDS/HIV Anemia Artificial heart valve Artificial joint(s) Blood disease Heart lesions Pacemaker Arthritis Asthma High cholesterol Cancer Diabetes Emphysema Glaucoma Breathing issues Sinus issues Stroke Thyroid problems Tuberculosis Ulcer Epilepsy Fainting or dizziness Headaches Hepatitis Herpes Kidney or Liver disease Anxiety Psychiatric care Any other medical issues we should know about? * Please list any medications you're taking: * Are you pregnant or nursing? * Yes No Thank you so much for providing this information. We look forward to seeing you at your first visit!
