top of page
Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you.

We look forward to working with you in maintaining your dental health.

Patient Information

Primary Insurance

Person Responsible for account

(If different from patient's)

Additional Insurance

Is patient covered by additional insurance

Dental History

Check If you have had problems with any of the following

Medical History

Have you ever use a bisphosphone medication? Common brand names are Fosamax, Actonel, Atevia, Didronel, Boniva.

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combination of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

Have you had any serious illnesses or operations?

Have you ever had a blood transfusion?

(Women) Are you pregnant?

Nursing?

Taking birth control pills?

Check If you have or have had with any of the following :

Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as

completely as you can. If you have questions we'll be glad to help you.

We look forward to working with you in maintaining your dental health.

Patient Information

Primary Insurance

Person Responsible for account

Additional Insurance

Is patient covered by additional insurance

Dental History

Check If you have had problems with any of the following