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03/30/2026Click to Sign
Prefix
Sex
Have you or a family member ever been a patient of our practice?
Guarantor
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03/30/2026Click to Sign
Sex - Secondary Dental Insurance
Sex - Primary Dental Insurance
Sex - Primary Medical Insurance
Sex - Secondary Medical Insurance
Location Office
Office Location
Are you in good health?
Have there been any changes in your physical health in the past year?
Are you now under the care of a physician?
If you had any illnesses, operation, or been hospitalized in the past 5 years?
Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around the mouth?
Do you have a prosthetic join/implant?
Have you ever had general anesthesia?
Have you or a family member had any unusual or serious reactions to general anesthesia?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Is there any condition concerning your health that the doctors should be told about?
Do you wish to talk to the doctor privately about anything?
If you are having IV anesthesia today, have you had anything to eat or drink in the last 6 hours?
Have you had or currently have:
Is there a possibility of pregnancy?
Are you nursing?
Are you taking birth control pills?
Are you now taking any of the following?
Allergies:
Family History:
Is this visit related to an accident?
If yes, what type of accident?
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03/30/2026Click to Sign
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03/30/2026Click to Sign
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03/30/2026Click to Sign
How do you want to be addressed when summoned from the reception area?
03/30/2026Click to Sign
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Confirm my appointments, treatment, and billing information via:
I authorize information about my health be conveyed via:
I approve being contacted about special services, events, fund raising efforts, or new health information on behalf of this healthcare facility via:
If texting or emailing becomes an option with this office in the future, do you authorize this type of contact?
If Yes - Authorize type of contact
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03/30/2026Click to Sign
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