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Primary Dental Insurance
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Secondary Dental Insurance
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Medical History




Abnormal bleeding: Yes No Alcohol / Drug Abuse: Yes No Anemia: Yes No Arthritis: Yes No Artificial Bones / Joints: Yes No Asthma: Yes No Blood Transfusion: Yes No Cancer / Chemotherapy: Yes No Colitis: Yes No Congenital Heart Defect: Yes No Diabetes: Yes No Difficulty Breathing: Yes No Emphysema: Yes No Epilepsy: Yes No Fainting Spells: Yes No Frequent Headaches: Yes No Glaucoma: Yes No Hay Fever: Yes No Heart Attack: Yes No Heart Murmur: Yes No Heart Surgery: Yes No Hemophilia: Yes No Hepatitis: Yes No Herpes / Fever Blisters: Yes No High Blood Pressure: Yes No HIV+ / AIDS: Yes No Hospitalized for any reason: Yes No Kidney Problems: Yes No Liver Disease: Yes No Low Blood Pressure: Yes No Lupus: Yes No Mitral Valve Prolapse: Yes No Pacemaker: Yes No Physciatric Problems: Yes No Radiation Treatment: Yes No Rheumatic / Scarlet Fever: Yes No Seizures: Yes No Shingles: Yes No Sickle Cell Disease: Yes No Sinus Problems: Yes No Stroke: Yes No Thyroid Problems: Yes No Tuberculosis (TB): Yes No Ulcers: Yes No Veneral Disease: Yes No
Aspirin: Yes No Codeine: Yes No Dental Anesthetics: Yes No Erythromycin: Yes No Jewelry / Metals: Yes No Latex: Yes No Penicillin: Yes No Tetracycline: Yes No Other: Yes No

Emergency Contact

Dental History

We'll have Consent for Treatment and HIPPA forms ready for you to sign when you come in to see us.