Patient Information *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you in the middle of any other dental care?

Crowns

Fillings

Dentures

Bridges

Root canal therapy

Other

Checklist: Over the previous 12 months *

Did you have any chest pain that could have been from the heart?

Do you have an abnormal heart valve or heart murmur?

Have you had a blackout or ‘funny turn’?

Are you troubled with pain or aching in the stomach or abdomen?

Have you had jaundice or hepatitis?

Have you experienced any abdominal bleeding or bruising?

Do you have diabetes?

Is there any chance you could be pregnant?

Did you smoke in the previous 6 months?

Appointment Reminders

SMS Text

Email

Phone

Clinical Recalls

SMS Text

Email

Phone