Date: 1/25/2021
Signature will be recorded later.
Name of former dentistCity/StateDo you have BiteWing x-rays that are less than 1 year old?Date of last cleaning and examRelationshipEmergency ContactPhoneList all medications or drugs you are now taking:NoneFirst Name:Birthdate:Medical HistoryLast Name:Name of Medical Doctor:City/State:Reason for today`s visitAre you in pain?Unusual reaction to dental injections?New patients:Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?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:NoneTobacco use? If so, what kind and how much?None