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Dental Screening Form
Date
Patient Name
Birthdate
Email
Phone
--
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?
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

Dental Screening Form