Free Dental Clinic Information Form Template
Dental Clinic Information Form
Please fill out this form to provide essential details for your dental care and treatment.
Personal Information
Name
Date of Birth
Gender
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Male
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Female
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Phone number
Address
Emergency Contact
Name
Relationship
Phone number
Dental History
Do you have any of the following?
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Cavities
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Gum Disease
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Tooth Sensitivity
-
Previous Dental Treatments
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How often do you visit the dentist?
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Regularly
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Occasionally
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Rarely
Do you smoke or use tobacco?
Medical History
Do you have any of the following?
Please check all that apply.
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Diabetes
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Heart Disease
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High Blood Pressure
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Allergies
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Current Medications
Are you currently pregnant?
Consent and Signature
I hereby consent to receive dental treatment and understand that my personal information will be kept confidential.
Name:
Date:
Thank you for providing the necessary information!
We look forward to taking care of your dental health.
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