SeamlessDocs

Do you have secondary Dental Insurance?
Have you or any member of your family been a patient of our office?
Select all that apply:
Are you under a physician's care for a particular problem?
Select all that apply:
Allergies
Are you in good health?
Have there been any changes in your health in the past year?
Have you ever had any serious illnesses, emergency room visits, or hospitalizations?
Have you ever had surgery before?
Did you have any complications with the surgery or with the anesthesia used, including nausea, vomiting, or difficulties with anesthesia?
Select all that apply:
Any psychiatric diagnosis or other emotional problems?
Are you pregnant or is there any chance you may be pregnant?
Are you nursing?
Do you take oral contraceptives?
Do you or have you ever taken bisphosphonate medications for osteoporosis, cancer, or multiple myeloma (such as Fosamax, Actonel, Boniva, Reclast, Aredia, or Zometa)?........... If so, for how long (months or years
Any difficulties or serious problems with previous dental treatments?
Any family members that have difficulty with IV or general anesthesia?
Any other concerns or health problems that may affect treatment in our office?
Have you had anything to eat or drink within 6 hours?
Are you under the care of a specialist?
If yes, please specify:
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