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(818)505-0106
(818)505-0106
5300 Lankershim Blvd 105
North Hollywood, CA 91601
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New Patient Form
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Name
First
Last
Preferred Name
Email Address
Phone Number
Mailing Address
City
State
Zip Code
Gender
Male
Female
Date of Birth
Social Security
Dental Insurance
Name of Spouse
Spouse Date of Birth
Spouse Member ID or SSN
Whom may we thank for referring you?
Does dentistry make you nervous?
No
Slightly
Moderate
Extremely
What is the reason for your visit?
When was your last dental visit?
Is your general health good?
Yes
No
If not, please explain
Do you take any medications?
Please list them
Have you had any hospitalizations in the past?
Please list the reason(s)
Do you have or have you had history of
NONE
Heart disease/heart attack
Artificial joints
Stomach problems
Heart murmurs
High blood pressure
Seizures
Surgeries
Diabetes
Cancer
Radiation therapy
Rheumatoid arthritis
Breathing disorder
Kidney disease
Liver disease
Stroke
Osteoporosis
Hepatitis A B C
Herpes or other STD
HIV
Depression
Anxiety
Are you allergic to anything?
Yes
No
Please list
i.e penicillin, latex, local anesthetic, valium, or anything else)
Have you ever taken bisphosphonate (fosamax)?
Yes
No
Have you ever taken fen-phen?
Yes
No
Are you possibly pregnant?
Yes
No
Do you have any diseases not asked?
Yes
No
Do you need to be pre-medicated for dental work?
Yes
No
Do you authorize the performance of diagnostic x-ray:
Yes
No
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