New Patient Form



PATIENT REGISTRATION


   

I, have receive a copy of this office's Notice of Privacy Practices.

I, authorize the following person(s) to have access to information covered and under the Privacy Practice regarding myself.

Dental History

Please check any of the following problems that apply to you. Yes No
Sensitivity (hot, cold, sweet, pressure) Where? UR LR UL LL
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
Bad breath
Do you have or have you had any of the following?    
Dentures
Partial Denture
Braces
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
Close spaces
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




Medical History

Please check any of the following problems/conditions that apply to you.




Consent:

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.


Dental Designs Of Plantation

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