Signature will be recorded later.
Date: 12/15/2018Date of last cleaning and examCity/StateName of former dentistDo you have BiteWing x-rays that are less than 1 year old?Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?New patients:Are you in pain?Unusual reaction to dental injections?Tobacco use? If so, what kind and how much?NoneList any medical conditions you may have including: asthma, bleeding problems, cancer, diabetes, heart murmur, heart trouble, high blood pressure, joint replacement, kidney disease, liver disease, pregnancy, psychiatric treatment, sinus trouble, stroke, ulcers, or history of rheumatic fever or of taking fen-phen:NoneList all medications or drugs you are allergic to:NoneList all medications or drugs you are now taking:RelationshipPhoneEmergency ContactCity/State:Name of Medical Doctor:Birthdate:First Name:Last Name:Medical History