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Welcome Form
Welcome Form
Your Information
First Name:
Last Name:
Date of Birth:
Social Security #:
Driver's License:
Issuing State:
Address:
City:
State:
Zip:
Name of Insurance:
Group #:
Insurance Telephone:
Insurance Information
First Name:
Last Name:
Date of Birth
Social Security #:
Driver's License:
Issuing State:
Dental Insurance:
Yes
No
Status:
Child
Single
Married
Widowed
Divorced
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Employer:
Occupation:
Employer Address:
City:
Zip:
State:
Medical Information:
Physician's Name:
Physician's Telephone:
Check all that cause allergic reactions:
Aspirin
Penicillin
Codeine
Latex
Add any additional allergic substances:
Are you taking any of the following:
Asiprin
Insulin / Diabetic Drugs
Blood Thinners
Tranquilizers
Recreational Drugs
Steroids
Other
List any serious prescription/over the counter drugs not listed:
Check any of the following symptoms that you may have experinced:
Asthma
HIV / AIDS
High Blood Pressure
Drug Abuse
Fever Blister
Diabetes
Heart Murmur
Hepatitis
Heart Attack
Mitral Valve Prolapse
List any serious medical conditions you may have experinced not listed:
I have joint replacement or heart valve replacement:
In Case of Emergency
His / Her Name:
Relation to you:
Telephone:
Address:
City:
State:
Zip:
Dental History
Reason for your appointment today:
Are you currently in pain?
Do you need to be on antibiotic premedication before dental work?
Do your gums bleed?
Do you smoke?
Are you happy with the way your smile looks?
How happy are you with the way your smile looks?
(On a 1-5 scale)
1
2
3
4
5
What would you change about your smile?
Please tell us how you would like to change your smile.
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