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Family Dentistry of Blairsville
NEW PATIENT APPLICATION FORM
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Full Name
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Date of Birth
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Gender
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Mailing Address
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Phone Number
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Email
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Preferred Contact Method
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Phone
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Insurance Information
(If applicable) Primary Insurance Provider
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Date of Last Dental Visit
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Previous Dentist
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Reason for Necessary Visit
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Did you have any outstanding dental needs with your last dental provider?
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Do you experience any of the following? (Check all that apply)
Tooth Pain
Sensitivity
Jaw Pain
Bleeding Gums
Bad Breath
Dry Mouth
Grinding/Clenching
Other:
Please check any treatments you think you may need:
Comprehensive care/Preventive Care
Extractions
Partials
Whitening
Botox
Crowns
Dentures
Implants
Clear Aligner Therapy
Routine Maintenance
Cavity Control
Sleep Apnea oral appliance/ or getting off CPAP
Fillings
Other:
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