Patient Information

    Date of Birth (required)
    Sex (required)

    Address Information (required):

    How did you find out about us? (required)

    Phone Numbers

    IN CASE OF EMERGENCY, CONTACT

    Dental Information

    Date of last dental visit:Date of last X-ray:Select "yes" or "no" to indicate if you have had any of the following:

    Bad breath
    Bleeding gums
    Blisters on lips or mouth
    Burning sensation on tongue
    Chew on one side of mouth
    Cigarette, pipe, or cigar smoking
    Clicking or popping jaw
    Dry mouth
    Fingernail biting
    Food between the teeth
    Foreign objects
    Grinding teeth
    Gums swollen or tender
    Jaw pain or tiredness
    Lip or cheek biting
    Loose teeth or broken fillings
    Mouth breathing
    Mouth pain, brushing
    Orthodontic treatment
    Pain around ear
    Periodontal treatment
    Sensitivity to cold
    Sensitivity to heat
    Sensitivity to sweets
    Sensitivity when biting
    Sores or growths in your mouth

    Health History

    Date of Last Visit:
    Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
    Are you required to pre-medicate before dental treatment?



    Select "yes" or "no" to indicate if you have had any of the following:

    AIDS/HIV
    Anemia
    Arthritis, Rheumatism
    Artificial Heart Valves
    Artificial Joints
    Asthma
    Back Problems
    Bleeding abnormally, with
    extractions or surgery
    Blood Disease
    Cancer
    Chemical Dependency
    Chemotherapy
    Circulatory Problems
    Congenital Heart Lesions
    Cortisone Treatments
    Cough, persistent or bloody
    Diabetes
    Emphysema
    Do you wear contact lenses?
    Epilepsy
    Fainting or dizziness
    Glaucoma
    Headaches
    Heart Murmur
    Heart Problems
    Hepatitis
    Herpes
    High Blood Pressure
    Jaundice
    Jaw Pain
    Kidney Disease
    Liver Disease
    Low Blood Pressure
    Mitral Valve Prolapse
    Nervous Problems
    Pacemaker
    Psychiatric Care
    Radiation Treatment
    Respiratory Disease
    Rheumatic Fever
    Scarlet Fever
    Shortness of Breath
    Sinus Trouble
    Skin Rash
    Special Diet
    Stroke
    Swollen Feet or Ankles
    Swollen Neck Glands
    Thyroid Problems
    Tonsillitis
    Tuberculosis
    Tumor or growth on
    head or neck
    Ulcer
    Venereal Disease
    Weight Loss, unexplained

    Women:

    Are you pregnant (required)?

    Due Date:

    Are you nursing?

    Taking birth control pills?

    Medications

    List any medications you are currently taking:

    Allergies

    Check all that apply (required):

    Other:

    Privacy Practices and Office Policies

    Referral Policy

    Privacy Practices and Acknowledgement

    A hardcopy of our HIPAA Privacy Practices are available to all patients in the office. This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

    Authorization to Discuss Protected Health Information

    I give permission to verbally discuss the following dental/medical and billing information about me: Scheduling/Appointment Information, Medical/Dental Information; including my symptoms, diagnosis, medications & treatment plan, (this may also include information about behavioral health, chemical dependency, prenatal care, pregnancy, family planning & STD testing/treatment) Lab Test Results, Billing & Payment Information etc.

    I understand that if an individual is not listed here my information will not be released and it is my responsibility as the patient to update and amend/cancel this form in writing. I understand that by not listing an individual on this form that the office will not release any information to them without an amended form in writing. I understand that if I am completing this information under "Power of Attorney" I will need to provide documentation to The Denture Doctor for their records.

    Social Media/Satisfaction Review Policy

    I am aware that The Denture Doctor may text or e-mail a link to a social media platform in order to submit a review of your recent experience. Text message rates may apply to messages sent and all fees associated are not the responsibility of The Denture Doctor. It is my responsibility as the patient to update this form and any contact information associated with my account.


    Additional Notes: