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In order to better serve you and protect your health, we need to know your dental
and medical history. Your history will be carefully reviewed and used to aid us
in giving you the highest dental care.
Please enter your information below and press the Submit button at the bottom of the page.
We will process your request at our earliest convenience and contact you with any further instructions.
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Date/Time
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Patient Name
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Parent/Guardian
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Street Address
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City
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State
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Zipcode
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Phone
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Email
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Physicians Name
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Physicians Phone
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Pharmacy #
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Are you allergic to penicillin, aspirin, codeine, local anesthetics,
latex, metals, or any other medications?
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Are you having pain or discomfort at this time?
If yes, please describe and tell us for how long:
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Are you a patient that requires a premedication?
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If patient is a child and needs a prescription, we will need
the patients weight.
Please enter the patients weight here:
lbs
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Is there dental insurance? If yes, please provide all information for eligibility
to be checked prior to your appointment:
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Additional comments or information:
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