Best Number to Call *Required
Would you like us to contact your dentist?
We recommend routine dental exams and
If you do not have a regular Dentist or Hygienist would
you like us to provide these services?
Do you have any dental problems now? *Required
Are any of your teeth sensitive to:
Have you noticed any mouth odors or bad tastes? *Required
Have you had plate(s) or mouth guard(s)? *Required
Do your gums bleed or hurt? *Required
Have your parents had gum disease or tooth loss? *Required
Have you noticed any loose teeth or change in your bite? *Required
Does food get caught between your teeth? *Required
Do you feel nervous about treatment? *Required
Have you been under the care of a medical doctor during the past 2 years? *Required
Have you taken any medication or drugs during the past 2 years? *Required
Have you taken any prescriptions for weight loss (diet pills)? *Required
If yes, did you take any of the following?
If yes to any of the above, did you have a medical examination for heart issues? *Required
Are you aware of having an allergic or adverse reaction to any medications or substances? *Required
Have you been a patient in hospital during the past 5 years? *Required
Indicate which of the following you have had or have at present:
Do you have or have you had any disease, condition, or problem not listed? *Required
Terms and Conditions *Required
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner_ I have answered all questions to the best of my knowledge_Should further information be needed, you have my permission to ask the respective health care provider or agency who may release such information to you_ I will notify thedoctor/dentist of any change in my health or medication.