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Oral Exams
Teeth Whitening
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New Patient Form
Patient Medical Form
Patient Financial Form
COVID-19
Upgrades & Changes
What to expect
Insurance
Contact Us
Home
Welcome
Meet The Team
Our Goals
Services
Dental Crowns
Children
Dentures
Dental Bridges
Dental Fillings
Implant Crowns
Night Guards
Oral Exams
Peridontal Treatment
Preventive Program
Snore Guards
Teeth Whitening
Patient Info
Patient Forms
New Patient Form
Patient Medical Form
Patient Financial Form
COVID-19
What to expect
Upgrades & Changes
Insurance
Contact Us
Menu
Home
Welcome
Meet The Team
Our Goals
Services
Dental Crowns
Children
Dentures
Dental Bridges
Dental Fillings
Implant Crowns
Night Guards
Oral Exams
Peridontal Treatment
Preventive Program
Snore Guards
Teeth Whitening
Patient Info
Patient Forms
New Patient Form
Patient Medical Form
Patient Financial Form
COVID-19
What to expect
Upgrades & Changes
Insurance
Contact Us
Patient Medical Form
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541-488-9260
Medical History
Patient Name
Patient DOB
Please answer all questions regarding your medical history since your last visit to our office.
Have you changed your primary care physician?
Yes
No
If yes, name of new physician
Physician Phone Number
Are you currently under the care of a medical specialist?
Yes
No
If yes, name of specialist
Type of specialist
Have you had any health changes?
Yes
No
Describe These Changes
Have you had any medication changes?
Yes
No
If yes, please write changes on attached form.
If required to take a pre-med prior to dental procedures, have you taken it today?
Yes
No
Has your address or phone number changed
Yes
No
If yes write new phone number
New Address
Has your dental insurance changed?
Yes
No
If yes, name of new insurance company
ID#
Group #
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