Dental Clinic Information Form
Dental Clinic Information Form
To help us provide the best possible care and ensure your dental records are accurate, please complete the following form.
Personal Information
Name:
Date of Birth:
Gender:
-
Male
-
Female
-
Home Address:
Phone number:
Email:
Emergency Contact
Name:
Relationship:
Phone number:
Dental History
Date of your last dental visit:
Reason for your last dental visit:
Have you ever had any of the following dental procedures?
Check all that apply.
-
Fillings
-
Root Canal Treatment
-
Braces/Orthodontic Treatment
-
Tooth Extraction
-
Gum Surgery
-
Dental Implants
-
Are you currently experiencing any dental pain or discomfort?
If yes, please describe:
Do you have any concerns or problems with your teeth, gums, or jaw?
If yes, please describe:
Do you grind or clench your teeth?
Do your gums bleed when you brush or floss?
Medical History
Do you have any allergies (e.g., medications, latex, etc.)?
If yes, please list:
Are you currently taking any medications?
If yes, please list:
Do you have any chronic medical conditions (e.g., diabetes, heart disease)?
If yes, please list:
Have you had any surgeries in the last 5 years?
If yes, please describe:
Do you smoke or use tobacco products?
Do you consume alcohol regularly?
Are you pregnant or breastfeeding?
Consent and Signature
I, the undersigned, consent to dental treatment as discussed and recommended by the dental team. I understand that I can ask questions about my treatment at any time.
I acknowledge that the information I provided is accurate to the best of my knowledge and understand that this information will be used solely for my dental care and treatment.
Date:
Thank you for providing the necessary information!
We look forward to taking care of your dental health.
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