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Patient Intake Form

Please complete the Patient Intake Form which will provide important information that will allow our dentists to provide your assessment. To learn more about how we use your personal information, please review our Privacy Policy.

Do You Have, or Have You Had Any of These Health Concerns? (Please Select All That Apply)

Aspirin Allergy Asthma Blood Disease Breathing Problem Cancer Chemotherapy Chest Pains Diabetes Drug Addiction Emphysema Epilepsy or Seizures Excessive Bleeding Fainting Spells/Dizziness Frequest Headaches Glaucoma Hay Fever Heart Attack/Failure Heart Disease Heart Pace Maker Heart Trouble Hemophilia Hepatitis A Hepatitis B Hepatitis C Irregular Heartbeat Kidney Problems Latex Allergy Leukemia Liver Disease Local Anesthetics Allergy Low Blood Pressure Metal Allergy Pain in Jaw Joints Penicillin Allergy Problems With Anesthesia Sinus Trouble Stroke Taking Birth Control Tuberculosis Codeine Allergy Cold Sores/Fever Blisters Cortisone Medication Allergy High Blood Pressure Hives or Rash Hypoglycemia Tumors or Growths Ulcers

If You Have or Have Had a Medical Issue Not Listed Above, Please Describe Below:

If You Have Any Further Comments, Please Describe Them Below:

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Use of Personal Information Approval

I have read the Privacy Policy and agree to sharing my personal information with 780-DENTIST.

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780-DENTIST
(780-336-8478)

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MON-FRI 09:00 - 19:00
SAT-SUN 10:00 - 14:00

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