Patient Information Form - Ocean Dental Studio

  • PATIENT'S INFORMATION

  • Date of Birth:*
     - -
  • Registering for a child?*
  • Other parental consent required
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN CASE OF EMERGENCY, PLEASE NOTIFY:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • CONTACT OPTIONS

  • I prefer appointment reminders by*
  • Are any other members of your family patients at our practice?*

  • INSURANCE INFORMATION

  • Insurance Information*

  • Please complete the following if you have dental insurance

  • Date of Birth
     - -
  • Patient's relationship to subscriber

  • MEDICAL HISTORY

  • The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

  • Are you being treated for any medical condition at the present or any time within the past year?*
  • When was your last medical checkup?
     - -
  • Has there been any change in your general health in the past year?*
  • Are you taking any prescription, non-prescription medications, or herbal supplements?*
  • Do you have any allergies?*
  • Have you ever had a peculiar or adverse reaction to any medicines or injections?*
  • Please list below with approximate dates
     - -
  • Do you have or have you ever had asthma?*
  • Do you have or have you ever had any heart or blood pressure problems?*
  • Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*
  • Do you have a prosthetic or artificial joint?*
  • Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
  • Have you ever had hepatitis, jaundice, or liver disease?*
  • Do you have a bleeding problem or bleeding disorder?*
  • Have you ever been hospitalized for any illnesses or operations?*
  • Are there any conditions/diseases not listed that you have or have had?*
  • Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*
  • Do you smoke or chew tobacco products?*
  • Are you nervous during dental treatment?*
  • For women only: Are you pregnant or breastfeeding?
  • What is your expected delivery date?
     - -

  • DENTAL HISTORY

  • When was your last dental appointment?
     - -
  • How often do you see the dentist?
  • Have you ever whitened (bleached) your teeth?
  • Should be Empty: