2103 Telshor Ct
Las Cruces, NM 88011
(575) 522-8800 - Las Cruces
(575) 623-5711 - Roswell
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–4:00 PM
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Patient Name: Suffix
Relation to Patient
Is billing address different from physical address?
May we contact you by email?
May we contact you by text message?
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Relationship to Primary Dental Insured Party
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Relationship to Secondary Dental Insured Party
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Relationship to Medical Insured
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Have you or any relative had a life-threatening reaction to anesthesia?
Are you pregnant or nursing?
Do you have or have had these ailments?
List All Medications, Dosages, and Frequency
Have you had any serious illness, operation, or been hospitalized in the last five years?
Have you had a cold or sore throat in the past two weeks?
Are you wearing contact lenses?
Are you wearing a removable dental appliance?
Do you smoke?
Do you have any disease, condition, or problem not listed above that you think we should know about?
Have you ever taken medication for osteoporosis at any time in your life?
Have you ever used a CPAP machine or been diagnosed with sleep apnea?
Do you use marijuana in any form-medical or recreational?
CERTIFICATION: I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfcation. I will not hold my doctor or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.