First Name
Last Name
Birth Date
GenderMaleFemale
Address
City
State
ZIP
Email
Cell Phone
Emergency Contact
Phone
Medical Practitioner’s Name / Contact
How did you hear about us?
I live/work in areaI was referred bySocial mediaOther
Referred by
Other
No Dental InsurancePrimary Insurance
Name of Insurance Company Member ID
Heart disease or surgeryHigh/Low blood pressureDiabetes (Type 1 or 2)Respiratory issuesEpilepsy / SeizuresStrokeMental health conditionsCancer / ChemotherapyKidney or liver diseaseBleeding disorderAutoimmune conditionBone / Joint diseaseOsteoporosis treatmentBisphosphonate medicationHIV / AIDSTuberculosisHepatitis A, B, or CSmoker
No known allergiesYes - list allergies
No adverse reactionsYes - describe
NoYes - list all current medications
Last dental visit
Dental anxiety: YesDental anxiety: NoIf yes, what helps?Disability or mobility issuesRemote/rural residentLow English proficiencyCognitive impairment
I confirm the above information is accurate and complete. I understand that this information will be used to provide safe and appropriate dental care. I consent to treatment and the sharing of information with healthcare providers if needed.
