Your Name (required)
Your Email (required)
Reason for visit
Date of last dental visit/
Date of last dental x-rays
Physician or Clinic Name
Physician/Clinic Phone or Location
How often do you brush?
How often do you floss?
Do you smoke or use tobacco products?
Please list any medication you are now taking
*It is especially important to know if you are taking bone/osteoporosis medications (Fosamax,Boniva, Prolia, Reclast, or Actonel) tranquilizers, phenobarbital or dilantin, blood thinners (aspirin, Warfarin/Coumadin, Plavix, Xarelto, Eliquis), steroid medicines, nitroglycerin, arthritis or thyroid medicine.
Are you taking Birth Control Pills?
Are you pregnant? If yes, # of weeks
Are you nursing?
YesNo Are you having pain or discomfort now? If so, what?
YesNo Do your gums bleed when you brush?
YesNo Have you had periodontal or gum treatment?
YesNo Have you had any undesirable treatment experience? If so, what?
YesNo Do you have any sores or lumps in your mouth that don’t heal?
YesNo Are you unhappy with your smile? If so, why?
YesNo Have you had orthodontic treatment?
YesNo Are you currently under a physician’s care? If so, for what?
YesNo Have you had any illness or surgery in the past year? If so, what?
YesNo Are you changing dentists for any particular reason? If so, why?
Angina Pectoris/ Chest Pain
Artificial Heart Valve
Congenital Heart Defect
Congestive Heart Failure
C-PAP machine/Sleep Apnea
Hemophilia or Clotting Disorder
Hepatitis A, B and/or C
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Mental Health Care
Sickle Cell Disease
List any disease or condition not listed above
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(After you click Submit, please make sure you complete Registration and X-ray request forms)
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Specific date you would prefer
Specific time you would prefer
General day(s) of the week would you like to come in
General time(s) of the day would you like to come in
Please describe your appointment