Patient forms for print Please feel free to print out these patient forms and email them back to us at firstname.lastname@example.org Patient Dental & Medical Information Form Dental Record Release Form Online Patient Form Step 1 of 4 25% Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Number*Mobile NumberEmail* Date of Birth* Date Format: MM slash DD slash YYYY How were you referred to us? Health HistoryName of Medical DoctorHave you been under a Dr's care in the last year?YesNoIf so, for what reason?Are you taking any drugs or medication?YesNoIf so, for what reason?Have you ever had excessive bleeding from a cut or tooth extraction?YesNoAre you allergic to Penicillin or any other drugs?YesNoIf so, for what reason?Do you smoke cigarettes?YesNoDo you often have headaches or neck pain?YesNoWomen: Are you pregnant?YesNoAre you taking medication for bone deterioration or disease?YesNoHave you ever had any of the following? Rheumatic Fever Diabetes Anaemia or blood disease Radiation T'ments Hepatitis High blood pressure Tuberculosis Arthritis Heart Disease Cancer Osterporosis Dental HistoryWhy do you seek dental care at this time?Are you taking medication for bone deterioration or disease?YesNoAre you troubled by "bad breath"?Are you self conscious about the appearance of your teeth?YesNoHas the fear of discomfort kept you from having regular dental care?YesNoDo you snore?YesNo Personal HistoryHow long since your last dental examination?Were x-rays taken at that time?YesNoWhen did you last have your teeth cleaned?What was done at the last dental appointment?Have your wisdom teeth been removed?YesNoHave you lost other teeth?YesNoIf so have they been replaced?YesNoDoes food collect between your teeth?YesNoAre any of your teeth sensitive to hot, cold or sweets?YesNoDo your gums ever bleed or feel tender?YesNoHow often do you brush your teeth?Do you ever use dental floss between your teeth?YesNoPhoneThis field is for validation purposes and should be left unchanged. Send message This iframe contains the logic required to handle Ajax powered Gravity Forms. Don’t forget to share this via Twitter, Google+, Pinterest and LinkedIn.