• PATIENT INTAKE QUESTIONNAIRE

  • Your cooperation in completing this questionnaire is essential to providing you with the highest standard of dental care.  Please answer the questions accurately as you can.  All information is strictly confidential and will remain with this office. We understand the importance of protecting your personal information.

  • PLEASE BE PATIENT, IT IS DETAILED

    QUESTIONS WITH * MUST BE ANSWERED

  • PREVIOUS DENTIST / OFFICE INFORMATION:

    Fill in what you can!
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  • I release you from all legal responsibility that may arise from this authorization.  If I have not verified the dates of my last complete exam or radiographs, my insurance may not cover the treatment and I understand that I am responsible to pay all incured expenses.

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  • Insurance - Primary

  • Insurance - Secondary

  • IN CASE OF EMERGENCY:

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  • DENTAL SPECIALIST INFORMATION:

    If you have one or two!
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  • DENTAL HISTORY:

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  • MEDICAL HISTORY

  • PHYSICIAN / SPECIALIST INFORAMTION

    All questions marked with * must the answered.
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  • Obstructive Sleep Apnea Screening:

    Untreated moderate to severe Obstructive Sleep Apnea has been associated with hypertension, heart attack, stroke, obesity, motor vehicle accidents, memory impairment, impotence, headaches as well as decreased quality of life.
  • If you answered yes to 2 or more questions, it is very likley that you are at significant risk for obstructive sleep apnea.

    If you answered yes to 3 or more questions, it is very likley that you have moderate to severe obstructive sleep apnea.

  • ADDITIONAL INFORMATION

  • PAYMENT

  • Credit Card on file will be required at the first appointment.  Unless the patient will have a credit card with parents approval.

  • APPOINTMENTS

  • CANCELLATIONS AND NO SHOWS

  • EMERGENCY APPOINTMENTS

  • GUARANTEES

  • PATIENT GENERAL CONSENT

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