Signature will be recorded later.
Date: 3/25/2023Date 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?Reason for today`s visitUnusual reaction to dental injections?NoneTobacco use? If so, what kind and how much?List 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:List all medications or drugs you are allergic to:NoneNoneList all medications or drugs you are now taking:PhoneRelationshipEmergency ContactCity/State:Birthdate:Name of Medical Doctor:First Name:Last Name:Medical History