Stephen c. dow ell dds, i nc. w elcom e to our p r acti ce! (please print) today s date: appointment date: patient information patient s last name: first: is this your legal name? ? yes middle: if not, what is your legal name? ? mr. ? mrs. marital...
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Patient information and health history form dental history reason for todays visit date of last dental visit former dentist date of last dental xrays address have you had any of the following: bad breath grinding your teeth sensitivity to heat...
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1870 w. wayzata blvd po box 695 long lake, mn 55356 ph: 9524737151 fax: 9524751539 longlakedental uslink.net patient information name: date: last, first, middle initial date of birth: person responsible for the account: address: city, state, zip:...
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Consent for amalgam (silverfilling) replacement1. i hereby authorize dr.and/or other dentists orassistants as may be selected by him/her, to treat my condition(s). the procedure(s) necessary totreat the condition(s) have been explained to me, and...
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Patient medical history patients name: best phone: alternate phone: physicians name: physician phone: birthdate: preferred pharmacy: pharmacy phone: age: please list any medications you are currently taking: are you currently undergoing any type...
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The redwoods group dental record-keeping system medical-dental history patient?s name dob ssn instructions: to receive treatment in this office you must answer all questions on this history form. the questions asked relate directly to the safe and...
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Health ( e-mail: history form today's date: a d)a. american dental association .ada.org as required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain....
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X-ray request and release form date: / / patient name: requested by (if other then the patient): relationship to patient: exam date(s) requested: x-ray(s) to be sent/faxed to: i authorize the release of the x-rays(s) requested above. signature
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New patient medical &dental history formit is important to know details about your medical history as these could affect the success of your dental treatmentand how we can provide this treatment safely for you. please note that all information on...
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Medical and dental health history form getting to know you as our patient account number: date: patient name (?rst and last): name of previous dentist/location: date of last dental examination: date of last cleaning: why have you come to see us...
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Dr. alan litvinov 126 jackson road ext. penfield, ny 14526 tell# 585-377-2114 fax# 585-377-5501 patient's name: patient's date of birth: dear doctor, i hereby authorize you to release any information or records regarding my dental treatment to dr....
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Medical history patient name nickname age name of physician/and their specialty most recent physical examination purpose what is your estimate of your general health? excellent good fair poor do you have or have you ever had: 1. hospitalization...
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Name: date: 1 chart: university of washington school of dentistry - medical and dental history general information male c. weight: lbs. month day year female d. height: ft. inches e. highest grade of regular school that you have completed? f....
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Maryland uniform dental consultation referral form date of referral: patient information: name: (last, first, mi) date of birth (mm/dd/yy): phone: carrier information: name: address: member #: site #: phone number: ( ) ) facsimile/data #: (...
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Medical history patient name birth date although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. health problems that you may have, or medication that you may be taking, could have an...
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