Welcome to Sunlight Dental Clinic
13005 Greenville Avenue
California, TX 70240
(1800) 456 7890
Toll Free
Mon - Sat 9.00 - 19.00
Sunday CLOSED
Book an Appointment
New Patient Form
Dental Registration and History
Contact Informations
First Name
Last Name
Date Of Birth
Phone Number
Address
Postal Code
Email
Emergency Contact Information
First Name
Last Name
Relationship
Phone Number
Insurance Information
Do you have insurance coverage?
Yes
No
Insurance Company
Policy Plan #
Member ID
Previous Dentist
Name
Clinic Name or Phone Number
Family Physician
Name
Clinic Name or Phone Number:
Medical History
Are you being treated for any medical condition at the present or have you been treated within the past year
Yes
No
Please Explain
When was your last medical checkup?
Date:
Reason:
Has there been any changes in your general health in the past year?
Yes
No
Please Explain
Are you currently taking
ANY
medication, non-prescription drugs ,supplements,cannabis(pot), controlled substance like: methamphetamine, fentanyl, cocaine, morphine, ephedrine
Yes
No
Please Explain
Do you have any allergies? If yes please list using the categories below
Medications
latex/rubber products
Other (e.g foods)
No
Have you ever had a peculiar or adverse reactions to any medications or injections?
Yes
No
Please Explain
Do you have or have you had any of the conditions listed below? Please check.
Osteoporosis
Asthmas
High blood pressure
Heart disease
Organ transplant
Prosthetic or artificial joint
Heart attack
Stroke
Shortness of breath
Pacemaker
Lung disease
Cancer
Diabetes
Stomach ulcers
Thyroid disease
drug/alcohol dependency
Have you ever been hospitalized for any illnesses or operations? If yes please explain
Do you have any conditions or therapies that could affect your immune system? (e.g chemotherapy, leukemia, AIDS, HIV infection, Radiotherapy)
Covid -19 or any flu like symptoms
Other (please list)
No
Do you have a bleeding problem or bleeding disorder?
Yes
No
Please Explain
Do you smoke or chew tobacco products?
Yes
No
Please Explain
Are you breastfeeding or pregnant?(For Women Only)
Yes
No
If pregnant, what is the expected delivery date?
I hereby confirm that I have answered all questions regarding my health and medical history to the best of my knowledge.
Assignment of insurance (if applicable): I hereby authorize Sunlight Dental Clinic to release any information needed to my insurance company, and also authorize my insurance company to pay directly to this clinic benefits accruing to me under my policy.
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