Medical Form

Approximate date of last and cleaning check-up?

Who/Where was your previous dentist?

Have you had any dental x-rays in the last 2 years?
YesNo

If so, please provide the name of the dental office.

Do I have the permission to contact that office and have any recent X-rays transferred to our office?
YesNo

Any current dental discomfort or pain?

How did you hear about Us?

Were you referred to our office by one of our patients or to one of the dentists in particular?
YesNo

If so, who referred you or who were you referred to?

Do you have a dental insurance?
YesNo
If yes,please be sure to bring all your information with you to your next appointment.

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