6600 Mercy Court, Suite 220 Fair Oaks, CA 95628 (916) 965-7036
Patient Registration
Is the patient a minor?
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Family Information
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Previous Dentist
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Relationship to Patient
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Insurance Company
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Mouth Breather?
Feel Rested?
Seen ENT Specialist?
Snore?
Feel Sleepy?
Sleep Apnea?
AIDS
Alzheimer's
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Artificial Heart Valves
Artificial Joints
Asthma
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Vitamin B12 Deficiency
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Nail Biting
Thumb Sucking
Do gums bleed easily?
Under special care?
Dental restorations?
Other injuries?
Chipped teeth?
Pain or soreness?
Sensitive mouth?
Currently pregnant?
Adenoids removed?
Tonsils removed?
Taking medications?
Taking antibiotics?
Allergies?
Other diseases/problems?
Osteoporosis?
Taking Fosamax?
Taking Redux?
Other Specialists (if under special care)
Dental Restorations Details
Other Injuries Details
Chipped Teeth Details
Pain/Soreness Details
Sensitive Mouth Details
Pregnancy Details
Adenoids Removal Details
Tonsils Removal Details
Medications Details
Antibiotics Details
Allergies Details
Diseases/Problems Details
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Consent Name
Consent Date
I hereby authorize the dental staff to perform necessary dental services for the patient. I understand that I am financially responsible for all services rendered.