Are you currently under the care of a physician?
Have you ever had any serious illnesses or operations?
YesNo
Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken
Have you ever had head or neck radiation therapy?
Are you taking any blood thinners? If yes, which one(s)
List all medications you are taking:
Are you allergic to:
PenicillinClindamycinSulfa DrugsCodeineLatex
Are you pregnant?
Nursing?
Taking Birth Control
Allergies, hay fever, sinusitis
Emphysema
Pacemaker
Anemia
Epilepsy
Respiratory disease
Arthritis, Rheumatism
Fainting
Rheumatic fever
Artificial heart valve(s)
Headaches
Shortness of breath
Artificial joint (s)
Heart Murmur
Sickle Cell Anemia
Asthma
Heart Problems
Sinus trouble
Bleeding abnormally with surgery
Hepatitis type
Stroke
Blood disease, clotting disorders
Herpes
Slow healing wounds
Cancer
High blood pressure
Swelling of ankles/feet
Chemical dependency
Immune deficiency
Thyroid problems
Chemotherapy
Jaundice
Tonsillitis
Circulatory problems
Kidney disease
Tuberculosis
Long term cortisone/steroid use
Low blood pressure
Tumor or growths
Cough, persistent
Mitral Valve prolapse
Ulcers
Diabetes
Osteoporosis/osteopenia
Venereal Disease
Have you had an allergic reaction to local or general anesthetics?
Have you ever had trouble with/from prior dental treatment?
How did you hear about us?GoogleYelpMagazineReferredRadio / TvFacebookInstagramHealthgrades
