Free Dental Clinic Form Template
Dental Clinic Form
Please complete this form to help us provide the best care for your dental needs.
Personal Information
Name
Date of Birth
Gender
-
Male
-
Female
-
Phone number
Address
Emergency Contact Name
Emergency Contact Number
Medical History
Are you currently taking any medications?
If yes, please list them:
Do you have any allergies?
If yes, please specify:
Have you had any surgeries in the past?
If yes, please specify:
Do you have a history of any of the following?
-
Heart Disease
-
Diabetes
-
High Blood Pressure
-
Asthma
-
Stroke
-
Dental History
Do you have any current dental concerns or pain?
If yes, please describe:
Are you currently undergoing any dental treatments?
If yes, please describe:
How often do you brush your teeth?
-
Once a day
-
Twice a day
-
More than twice
-
Rarely
Do you floss regularly?
Consent and Acknowledgment
I hereby consent to the treatment or examination as deemed necessary by the dentist. I acknowledge that the information provided is accurate and complete to the best of my knowledge.
Name:
Date:
Thank you for providing your information.
We look forward to assisting you with your dental care!
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