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WELCOME!

Crystal Crown Dental

Patient Information

Birthday
Year
Month
Day
Multi-line address
How did you hear about us?
Do you have Dental Insurace?
No
Yes

Dental History

What is the reason for today's visit?
Emergency
Examination
Other
Do you grind or clench your teeth?
No
Yes
Have you been told that you snore loudly?
No
Yes
Have you been diagnosed with a snoring or sleep apnea condition?
No
Yes
Do you use a CPAP machine?
No
Yes

Medical History

(This information will remain confidential)

Are you presently under the care of any physician other than your family doctor?
No
Yes
Have you ever been hospitalized?
No
Yes
Are you pregnant?
No
Menopause
On Birth Control
Yes
Are you taking any drugs or medication at this time?
No
Yes
Do you have any medication allergies?
No
Yes
Do you suffer from any allergies (hay fever, latex etc.)?
No
Yes
Do you bruise easily or have prolonged bleeding?
No
Yes
Do you smoke?
No
Yes
Have you ever fainted, had shortness of breath or chest pains?
No
Yes

Do you have any history of the following conditions?

Do you have any history of the following conditions?

General Release / Patient Consent

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment, and I authorize this dental office to perform general dental treatments. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures. I hereby certify that I have been notified of the privacy policies of this office, who to contact regarding privacy concerns and how to request further information.

Self
Parent
Guardian

Thank You!

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All Rights Reserved

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