Address: South Jordan 11677 S 4000 W South Jordan, UT 84009 Provo 3610 North University Avenue, Suite 150 Provo, UT 84604 Payson 1107 South Highway 198 Payson, UT 84651 Lehi 139 N Hunters Grove Ln, Ste 150 Lehi, UT 84043 Phone: (801) 938-3412 - South Jordan (801) 356-2226 - Provo (801) 356-2226 - Payson (801) 901-8089 - Lehi
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Gender
Marital Status
(If patient is over 18 y/o and a full time student):
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Primary Dental Insurance
Primary Medical Insurance
Secondary Dental Insurance
Secondary Medical Insurance
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*Please answer all questions correctly and completely. Your answers are for our records only and will be kept confidential.
Please list all current medications, including diet pills, non-prescription, vitamins, homeopathic or natual remedies
Are you allergic to or have you had a reaction to any of the following?
Allergies
Are you now under the care of a physician
Do you have any of the following diseases of problems?
Have you taken tranquilizers, sleeping pills, antidepressants, and/or narcotics on a regular basis
Have you had any serious illness, operation, or hospitalization in the last 5 years
Do you wish to talk with the doctor about anything privately
Are you taking any blood thinners (Coumadin®, Plavix®, aspirin, vitamin E, ginkgo biloba)
Have you had any serious problems associated with any previous dental treatment
Are you wearing a removable dental appliance
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®)
Are you wearing contact lenses
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
Ingested Food or Drink
