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Contact Us
Home
Office
About The Doctors
Our Staff
Testimonials
Office Policies
Financial
Maps & Directions
Appointment Requests
News About Us
Woodbridge in the News
Burke in the news
Digital X-Rays
Intra-Oral Camera
Ultrasonic Scalers
Patient Info
First Visit
F.A.Q.
Patient Forms
Patient Support
Common Problems
Emergencies
Oral Hygiene
Foods To Avoid
Pediatric
Dental Sealants
Fluoride & Your Child
Nitrous Oxide for Children
Space Maintainers
Pregnancy, Hormones & Oral Health
Orthodontics
Invisalign®
Adolescent Orthodontic Care
Adult Orthodontic Treatment
Orthodontics & Dental Oral Hygiene
FAQ about Orthodontics
When To See An Orthodontist
General Dentistry
Chipped Teeth
Crowns & Bridgework
Porcelain Veneers
Teeth Whitening
FAQ About Root Canal Treatment
Root Canal Treatment
Tooth Sensitivity
Fluoride & Your Teeth
Oral Health & General Health
Tooth Extraction
Locations
Woodbridge Dental Office
Burke Dental Office
Dale City Dental Office
Contact Us
1
Patient Info
2
Emergency Contact
3
Insurance Info
4
Dental History
5
Medical History
6
Authorization
Adult or Child Patient?
Adult - I am the patient.
Child - I am completing this form for the patient.
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Employer Name
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Copay Amount (if known)
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Additional Insurance Coverage
*
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Employer Name
Work Phone Number
Copay Amount (if known)
Deductible (if known)
How Did You Hear About Our Practice?
Ad
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Other
Name of person referring (if applicable)
First
Last
Have your tonsils or adenoids been removed?
Yes
No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever had an injury to (select all that apply)
Teeth
Mouth
Chin
Do you have speech problems?
Yes
No
Do your gums bleed?
Yes
No
Do you smoke?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits?
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail biting
Thumb/ Finger Sucking
Chewing/Eating Problems
Are you currently being treated by a physician?
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No
Reason
Physician
Last Visit
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Phone
Do you have any allergies/sensitivities to medications or latex?
Yes
No
List of Allergies
Are you currently taking any prescription or over-the-counter medications?
Yes
No
Please list medications & dosages
Have you ever had a serious illness or operation? If yes, please describe.
Have you ever had a blood transfusion?
Yes
No
Date of Blood Transfusion
Month
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Are You Pregnant?
Yes
No
Nursing?
Yes
No
Take Birth Control Pills?
Yes
No
Check if you have or have ever had any of the following:
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
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Cough, Persistent
Coughing Blood
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Heart Problems
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Jaw Pain
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Liver Disease
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Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
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Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
Authorization
*
I acknowledge.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party
Date
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