Dental Clinic Form
Dental Clinic Form
Please fill out the form with your information below.
Personal Information
Name:
Enter your full name.
Date of Birth:
Select your date of birth.
Email:
Phone Number:
Enter your contact phone number.
Address:
Gender:
-
Male
-
Female
-
Emergency Contact Information
Name
Relationship:
Phone number
Dental History
Date of Last Dental Visit:
Reason for Your Visit Today:
How often do you brush your teeth?
-
Once a day
-
Twice a day
-
More than twice
How often do you floss?
-
Never
-
Occasionally
-
Always
Do you experience any of the following?
Sensitivity to hot or cold
Pain when chewing
Bleeding gums
Jaw discomfort
Medical History
Are you currently under the care of a physician?
If yes, please specify:
Have you had any major surgeries in the last 10 years?
If yes, please specify:
Please check if you have any of the following medical conditions:
-
Heart Disease
-
Diabetes
-
High Blood Pressure
-
Allergies
-
Do you take any medications?
If yes, please list:
Are you pregnant or nursing?
Insurance Information
Insurance Provider:
Policy Number:
Subscriber's Name:
Relationship to Subscriber:
Consent
By signing below, I certify that the information provided above is true and complete to the best of my knowledge. I agree to inform the dental clinic of any changes in my medical status or personal information.
Patient
Name:
Date:
Patient's Parent/Guardian
Name:
Date:
Thank you for providing your information.
We look forward to assisting you with your dental care!
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