• Dental Screening Form

• 
  
• Date
• Patient Name
• Birthdate
• Email
• Phone

  --
• Address

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Emergency Contact Name*
• Phone

  --
• 
  
• How did you hear about our practice?*

  Family/Friend Internet Search Provider List Dental Referral
• What brings you into our office today?*

  Regular Maintenance/Cleaning Xrays/Scan Pain/Tooth Problems
• Are you having any of the following problems? Select Bleeding Gums Grinding Teeth Jaw Pain Jaw Clicking Loose/Broken, Cracked Teeth Sensitivity
• Please describe any issues that you are currently experiencing?*
• Medications/Supplements

  Medication/Supplement Name	Dosage

• Please list any allergies.*
• Prior procedures

  Surgery/Procedure	Date

• Insurance Provider
• Subscriber Name
• Subscriber ID
• 
  
• I consent to this screening and treatment:
• Date