Patient Intake Form To help us deliver high standards of care, please fill these forms out as completely as possible. 1Patient Information2Dental History3Medical History Name:* First Last Gender:* Male Female Marital status: Married Single Divorced Birth Month*Please enter a number from 1 to 12.Birth Day*Please enter a number from 1 to 31.Birth Year*AgeSocial Security Number: I do not have n SSN International Patient, ExemptPhone*Email* Full mailing address:* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer Responsible party: Myself Someone else If someone else, what is the responsible party’s full name? Responsible party’s full mailing address: Street Address Address Line 2 City ZIP Code Responsible party’s phone number:Relationship to patient: How did you hear about us? Emergency contact name: First Last Emergency contact number: Do you currently have a dentist providing your dental healthcare Yes No Dentist name: First Last Dentist phone numberLast visit Month Day Year Please select your interests in our dental practice: Restorative Cosmetic Procedures Establishing Dental Care Consultation Only-(Please note: a dental cleaning is required prior to starting restorative dental treatment) Do your gums bleed while brushing or flossing? Yes No Are your teeth sensitive to hot or cold liquids/foods? Yes No Are your teeth sensitive to sweet or sour liquids/foods? Yes No Do you have bad breath even after brushing? Yes No Do you feel pain from any of your teeth? Yes No If yes, please explain Do you have any sores or lumps in or near your mouth? Yes No Have you ever experienced any of the following problems in your jaw? Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing Injury to neck, head, or jaw Do you have frequent headaches? Yes No Do you clench or grind your teeth? Yes No Do you bite your lips or cheeks frequently? Yes No Have you ever had any difficult extractions in the past? Yes No Have you ever had any prolonged bleeding following extractions? Yes No Have you had any orthodontic treatment? Yes No Do you wear dentures or partials? Yes No Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Yes No Do you like your smile? Yes No Are you happy with the color of your teeth? Yes No Have you ever had teeth whitening? Yes No Are you happy with the position of your teeth? Yes No If yes, which process did you use and when was the last time you had it? Physician name First Last Physician Phone numberPhysician Last visit Month Day Year Are you under medical treatment now? Yes No Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? Yes No If yes, please explainAre you taking any medication(s) including non-prescription medicine? Yes No If yes, what medications are you taking?Do you use tobacco? Yes No Do you use controlled substances or Marijuana Prescription? Yes No Are you allergic to or have you had any reactions to the following? Aloe Vera Ibuprofen Latex Rubber Local Anesthetics (e.g. Novocain) Any Metals (e.g. nickel, mercury, etc.) Penicillin or any other antibiotics Other Please indicate what 'other' is:* Are you pregnant or think you may be pregnant? Yes No Are you nursing? Yes No Are you taking oral contraceptives? Yes No Do you have any of the following medical conditions? AIDS or HIV Infection Anemia Angina Arthritis Asthma Cancer Cardiac Pacemaker Chest Pains Diabetes Easily Winded Emphysema Epilepsy / Convulsions Fainting / Seizures Frequently Tired Glaucoma Hay Fever / Allergies Heart Attack Heart Disease Heart Murmur Heart Trouble Hepatitis / Jaundice High blood pressure Joint Replacement or Implant Kidney Diseases Liver Disease Low Blood Pressure Radiation Therapy Recent Weight Loss Respiratory Problems Rheumatic Fever Sexually Transmitted Disease Stomach Troubles / Ulcers Stroke Thyroid Problem Tuberculosis Other Please indicate what 'other' is:* Appointment cancellation policy In order to provide the finest dental treatment, we must utilize our resources efficiently and effectively. For your appointment, we allot a specific amount of Dr. Saleh’s time just for you. As a courtesy, we ask that you give us notice at least 24 hours in advance for dental cleanings and minor restorative procedures and 48 hours in advance for major cosmetic treatments like veneers for appointment changes or cancellations. This will allow enough time to schedule another patient in your place, as we always have patients waiting for openings. Should you need to reschedule or cancel your appointment without proper notice, you will incur a $75 cancellation/rescheduling fee for dental cleanings and minor restorative procedures and $200/hr blocked on the schedule for major cosmetic treatments like veneers. This fee will be charged to your credit card that will be kept in your patient file for this reason only. Contact Us to Schedule an Appointment
