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Home PhoneWork PhoneWireless PhoneEmailText

Preferred Contact Method (for confirmations)
Home PhoneWork PhoneWireless PhoneEmailText

Preferred Contact Method (for Reacll)
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Student status if dependent over 19 (for ins)
None StudentFull TimePart Time

How did you hear about us?

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Address 2

Home Phone

Relationship to Subscriber
SelfSpouseChild

List all medications you are currently taking:

Are you allergic to any of the following?
AnestheticAspirinCodeineIbuprofenIodineLatexPenicillinSulfa
Other allergies not listed above:

Do you have, or have you had, any of the following medical conditions?
AsthmaBleeding ProblemsCancerDiabetesHeart MurmurHeart TroubleHigh Blood PressureJoint ReplacementKidney DiseaseLiver DiseasePregnancyPsychiatric TreatmentRheumatic FeverSinus TroubleStrokeUlcers
Pregnancy - Due date:

Other conditions not listed above:

Tobacco use? If so, what kind and how much?

Unusual reaction to dental injections?

Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?

Do you have BiteWing x-rays that are less than 1 year old?