Date: 2/16/2019
Signature will be recorded later.
Date of last cleaning and examCity/StateName of former dentistDo you have BiteWing x-rays that are less than 1 year old?Unusual reaction to dental injections?Are you in pain?NoneNew patients:Tobacco use? If so, what kind and how much?List all medications or drugs you are allergic to: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:NoneYesNoneAre you currently taking any bisphosphonates or blood thinners?List all medications or drugs you are now taking:NonePhoneRelationshipEmergency ContactCity/State:Medical HistoryName of Medical Doctor:Birthdate:First Name:Last Name: