Name, Address, & telephone of a relative not living with you
How Did you hear about our office?
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Authorization to Release Information
Please check any of the following problems that apply to you.
Sensitivity (hot, cold, sweet, pressure)
Headaches, earaches, neck, pain
Jaw joint pain
Teeth or fillings breaking
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, tipped or shifting teeth
Do you have or have you had any of the following?
Periodontal (gum) treatment
If you could whiten your teeth for a cost anyone could afford, would you do it?
Do you smoke or use chewing tobacco?
If I could change my smile, I would:
Make it whiter
Make it straighter
Replace black metal fillings with tooth colored restorations
Repair chipped teeth
Replace missing teeth
Replace old crowns that don't match
Have a smile makeover
Please share the following dates:
Please check any of the following problems/conditions that apply to you.
Are you allergic or have you reacted advertisely to any of the following medication?
The undersigned hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a through diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I have read, understand and agree to the above terms and conditions.