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quesionaire
 
(800) 670-8450
First Name
Last Name
Address
City
State
Zip
Country
Phone # (if none, put none)
Email (if none, put none)
Date of Birth
Procedure(s) Requested:
Gender Male       Female
Height
Weight
Do you smoke?
Please Check all that Apply
 
Addiction to alcohol or drugs
Arthritis
Asthma/Breathing Problems
Autoimmune
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic, Long-term Steroids (past or present)
Chronic Pancreatitis
Cirrhosis of the Liver
Current Infections
Exposure to Tuberculosis
GERD (acid reflux)
Heart Murmur
Hepatitis
Heart or Vascular disease
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hypertension/ High Blood Pressure
Metabolic Conditions. (i.e.hypothyroidism)
Previous reactions to Anesthesia Clots
Seizures or Epilepsy
Sleep Apnea
Stroke
Thromboembolism
 
Do you have any medical condition that you have been told would diqualify you for any type of dental procedure or surgery?
Do you have special needs that need accomodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
If you said yes to any above, please explain
How long have you had these dental needs?
Do you have current xrays or a dental treatment plan?
What dental procedures or surgery have you had previously?
Your Medical Provider
Provider Contact #
Do we have permission to contact?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
 
 
 


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