Please enter your Patient Information before your visit.
Do you have insurance?
Name of insured and relationship to patient:
Birthdate/SSN of Insured:
Group #/Policy ID:
Please check the box if you have (or have had) any of the following:
High Blood Pressure
Low Blood Pressure
AIDS or HIV infection
Women Only: Please check the box if the information applies to you.
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?
Allergies: Check the box if you are allergic or have had allergic reactions to the following.
Local anesthetics (e.g. Novocain)
Penicillin or any other antibiotics
Any metals (e.g. nickel, mercury, etc.)
Medication/substances: Please check the box if you use the following.
Viagra/Revati/Cialis/ or Livitra
Please list any medications you take:
Dental History: Please check the box if the following applies to you.
My gums bleed when I brush or floss
My teeth are sensitive to hot or cold foods
My teeth are sensitive to sweet or sour liquids or foods
I have had a head, neck, or jaw injury
I have difficulty chewing
I have sores or lumps in or near my mouth
My jaw clicks
I have jaw pain
I have frequent headaches
I clench or grind my teeth
I bite my lips or cheeks frequently
I have had difficult extractions in the past
Date of Last Dental Exam:
If you have had any orthodontic treatment, please explain:
If you wear dentures or partials, please input the date of placement:
Do you like your smile?
Never submit passwords through Google Forms.
This form was created inside of HB Dental.
Terms of Service