Patient Registration Form

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Gender
Marital Status
Marital Status
Gender
Have you had any serious illness, operation, or hospitalization in the last 5 years
Are you taking any blood thinners (Coumadin®, Plavix®, aspirin, vitamin E, ginkgo biloba)
Are you wearing a removable dental appliance
Do you have any of the following diseases of problems?
Allergies
Are you now under the care of a physician
Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in/around mouth
Have you had an artificial joint replacement (knee, hip, shoulder, etc.)
Have you taken Bisphosphonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast®, Fosamax®, Boniva®, Actonel®, Boniva®, Aredia®, or Zometa®)
Have you taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis
Have you had any serious problems associated with any previous dental treatment
Are you wearing contact lenses
Do you wish to talk with the doctor about anything privately
Ingested Food or Drink
Are you pregnant or trying to become pregnant
Do you have problems associated with your menstrual period
Are you nursing
Are you taking birth control pills
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06/21/2026Click to Sign
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06/21/2026Click to Sign
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06/21/2026Click to Sign
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