Patient Intake Form To help us deliver high standards of care, please fill these forms out as completely as possible. 1Patient Information2Dental History3Allergies4Medical History Name:* First Last Gender:* Male Female Marital status: Married Single Divorced Birth Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberHiddenBirth MonthPlease 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 visitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please 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 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 Difficulty in opening or closing Difficulty in chewing Injury to neck, head, or jaw Do you clench or grind your teeth? Yes No Do you bite your lips or cheeks frequently? Yes No Have you had any Orthodontic treatment? (Invisalign or braces) Yes No Do you like your smile? (color, position, shape or size) Yes No Have you ever had teeth whitening? Yes No Have you ever had an adverse reaction to local anesthetics? (Lidocaine, Novocain, Carbocaine, Articane, Citanest Plain, etc.)* Yes No Are you allergic to or have you had any reactions to the following? Aloe Vera Ibuprofen/NSAIDs Tylenol/ Acetaminophen Latex/ Nitrile Penicillin/ Amoxicillin Coconut Oil Peppermint Topical Oral Anesthetics (Benzocaine topical) Local Anesthetics: (Lidocaine, Novocain, Carbocaine, Articane, Citanest) Metals (Nickel, Mercury, steel, etc.) Vitamin E Cinnamon Other Please indicate what 'other' is:* Physician name First Last Physician Phone numberPhysician Last visit Month Day Year Are you currently under medical treatment?*Enter N/A if not applicableHave you been hospitalized in the last 5 years?*Enter N/A if not applicableHave you had elective or cosmetic surgery in the last 5 years? Please list date and procedure:*Enter N/A if not applicableAre you currently taking any medications? Please list both dose and frequency:*Enter N/A if not applicableWomen ONLY: Are you currently pregnant or think you may become pregnant? Are you nursing? Are you currently on oral contraceptives?Do you have any of the following medical conditions? Acquired Respiratory Distress Syndrome Anemia Angina Anxiety OR Panic Disorders Arthritis (RA, OA) Asthma Bleeding or Blood Disorders Bowel or bladder Abnormalities Cancer Chemotherapy Chest Pains Chronic Obstructive Pulmonary Disease (COPD) Congestive Heart Failure (CHF) Degenerative Disc Disease (chronic back pain, spinal stenosis, history of disc dislocation) Depression Diabetes Emphysema Epilepsy or Seizure Disorders Fain Spells or Dizziness Hay Fevers or Allergies Headache or Migraines Heart Disease Heart Attack Heart Murmur Hearing Impairment Hepatitis A, B, or C High Blood Pressure Hypoglycemia Kidney Abnormalities Immunocompromised Immunosuppressant Medications Liver or Gallbladder abnormalities Low Blood Pressure Metal Implants or Joint Replacement Methemoglobinemia Multiple Sclerosis (MS) Osteoporosis Peripheral Vascular Disease (PVD) Radiation Therapy Recent Weight Loss Sexually Transmitted Infections Smoking (vape, tobacco, shisha, hookah) Stroke or TIA Tinnitus (ringing in ears) Tuberculosis Thyroid Related Diseases Upper Gastrointestinal Diseases (ulcer, hernia, reflux) Other Please indicate what 'other' is:* Appointment cancellation policy 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.Authorization and Release I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third-party payors and/or health practitioners. I authorize and request my insurance company to process claims submitted by Dr. Sam Saleh’s office on my behalf. I will pay the office up front for all services and understand that reimbursement from my insurance company will be sent directly to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Contact Us to Schedule an Appointment
