Home / Patient Information Form Patient Information Form Note: This form will not submit successfully unless all the fields marked with an * (asterisk) have entries. Personal InformationName(Required) First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)MaleFemalePhone #(Required)Other Phone #(Required)Email(Required) Enter Email Confirm Email Parent/Guardian (if applicable)Care Provider InformationGeneral Dentist Name/Office(Required)General Dentist Phone #(Required)Physician Phone #(Required)Specialist Phone #(Required)Emergency Contact InformationEmergency Contact Name(Required)Primary Phone #(Required)Alternative Phone #(Required)Second Emergency Contact(Required)2nd Primary Phone #(Required)2nd Alternative Phone #(Required)Medical History1. Have you ever been put under anesthesia before?(Required) No Yes What type of procedure?(Required)Where and When?(Required)Did you experience any complications? Please explain.(Required)2. Have you ever had sugery?(Required) No Yes What type of surgery?(Required)Where and When?(Required)Did you experience any complications? Please explain.(Required)3. Have you ever been hospitalized?(Required) No Yes For what reason?(Required)Where and When?(Required)How many days?(Required)4. Please check the box for any of the following conditions which may apply to you now or have applied to you in the past:(Required) ADHD Anemia Angina Pectoris Anxiety Artificial Heart Valve Artificial Joint Asthma Autism Bipolar Bleeding Disorder Cancer Cerebral Palsy Depression Developmental Delay Diabetes Down Syndrome Drug Addiction Epilepsy or Seizures Heart Attack Heart Disease Heart Murmur Heart Pacemaker, Defibrillator Heart Surgery Hepatitis High Blood Pressure HIV Mitral Valve Prolapse Reactive Airway Disease Recreational Drug/Alcohol Use Sickle Cell Disease Shunt Stroke Thyroid Disease Tuberculosis Wheel Chair Bound Other What type of Anemia?(Required)What type of Hepatitis?(Required)5. Do you smoke cigarettes or use smokeless tobacco?(Required) No Yes How many packs per day?(Required)6. Are you allergic to any medications such as local anesthetic, Penicillin, Erythromycin, Codiene, Aspirin, Sulfa, or any other medication?(Required) No Yes Please explain(Required)7. What medications are you currently taking?Name of MedicationDosagePrescribed Reason Add RemoveClick the + symbol to the right to add more blank fields. 8. What is your current height and weight?(Required) No Yes 9. When was the last time you were sick with a cold, cough or fever?(Required) No Yes 10. Is there anything that we haven’t asked that you feel would be important for us to know?(Required) No Yes Please explain(Required)
