Dental New Patient Intake

To save time at your appointment, please complete this form.

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Patient Health History

Are you pregnant? (women only)
Are you currently nursing?
Are you taking birth control pills?
Have you have any serious illnesses or operations?
Have you ever been diagnosed with any health conditions that require a pre-medication antibiotic 1 hour before dental treatment? (i.e. joint replacement)
Have you ever been treated with IV or oral bisphosphonates (drugs commonly used to treat osteoporosis or cancer i.e Fosamax, Boniva, Aredia,Zometa)?
Allergy to drugs: Sulfa, Latex, Penicillin, Aspirin, Codeine, or other drugs?
Have you ever had or do you now have any of the following (please select all that apply):

Thanks for submitting! If you have any questions or concerns, please contact us at (309) 867-2202