webteam@nuvolum.com
To better serve you, please take a couple of minutes to answer the following questions.
Please check any of the following problems that apply to you:
Do you have, or have you ever had, any of the following?
If you could whiten your teeth, at a cost that anyone could afford, would you like to?
If you could change your smile, would you? (please check all that apply):
How important is your dental health to you?
How would you rate your current dental health?
Where do you want your dental health to be?
The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.
Gender
Marital Status
Insurance Information
Thank you for filling out this form completely. It will allow us to serve you more effectively. If you have a question at any time, please ask us. We are happy to help.
Our office is HIPAA compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
Do you have a personal physician?
Are you currently under the care of a physician?
Please rate your current physical condition
Do you smoke or use tobacco in any forms?
Are you currently taking any prescriptions, over-the-counter, or herbal supplement drugs?
Have you ever taken fen-phen (also known as Redux or Pondimin)?
Are you taking any medications for osteoporosis?
Are you allergic to any of the following? (please check all that apply):
Have you ever had any of the following diseases or medical problems? (please check all that apply):
Do you have trouble sleeping?
Do you feel tired of fatigued after sleep?
Do you feel like you get enough sleep at night?
Do you have a CPAP?
Are you taking birth control pills?
Are you pregnant?
Are you nursing?
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental team to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
PAYMENT IS DUE IN FULL AT THE TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED.
