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Root Canal Therapy
Scaling & Root Planing
Extraction Site Preservation
Frenectomy
Dentures
Additional Dental Services
Night Guards
Oral Surgery
Occlusal Adjustment
Sports Mouthguards
TMJ Treatment
Snoring & Sleep Apnea Devices
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Dental Emergencies
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Intraoral Camera
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CEREC
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Resources
Smile Gallery
New Patient Forms
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FAQ’s
Resourceful Links
Dental Blog
Contact
Request an Appointment
Home
Make a Payment
Schedule Online
About
About Dr. Bandos
Our Staff
Our Office
Patient Video Testimonials
Services
Preventive Dental Services
Teeth Cleanings & Exams
Gum Disease Treatments
Tooth Fillings
Inlays & Onlays
Dental Sealants
Dental Hygiene
Cosmetic Dental Services
Dental Crowns
Cosmetic Bonding
Crown Lengthening
Porcelain Veneers
Teeth Whitening & Bleaching
ZOOM! Teeth Whitening
Dental Implants
Invisalign
Restorative Dental Services
Dental Bridges
Endodontics
Wisdom Teeth Removal
Root Canal Therapy
Scaling & Root Planing
Extraction Site Preservation
Frenectomy
Dentures
Additional Dental Services
Night Guards
Oral Surgery
Occlusal Adjustment
Sports Mouthguards
TMJ Treatment
Snoring & Sleep Apnea Devices
Pediatric Dental Services
Dental Emergencies
Technology
Panorex
Digital X-Ray
Oral Cancer Screenings
Intraoral Camera
Rotary Endodontics
CEREC
Oral Conscious Sedation
Resources
Smile Gallery
New Patient Forms
Dental Educational Videos
FAQ’s
Resourceful Links
Dental Blog
Contact
Request an Appointment
Medical History Form
Name
*
First
Last
Preferred Name
Email
*
How do you prefer to be contacted?
*
E-mail
Cell Phone
Home Phone
Work Phone
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Primary Dental Insurance
Insurance Name
Insured's DOB
Date Format: MM slash DD slash YYYY
ID #
Group #
Insured's Employers Name
Your current physical health is:
*
Good
Fair
Poor
Are you currently under the care of a physician?
*
Yes
No
Please explain:
Do you smoke or use tobacco in any form?
*
Yes
No
Have you had any metal rods, pins or implants?
*
Yes
No
Are you taking any prescription/over the counter drugs?
*
Yes
No
Please list each one:
*
For Women:
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
Week #:
Are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding
*
Yes
No
Alcohol/Drug Abuse
*
Yes
No
Anemia
*
Yes
No
Arthritis
*
Yes
No
Artificial Bones/Joints/Valves
*
Yes
No
Asthma
*
Yes
No
Blood transfusion
*
Yes
No
Cancer/Chemotherapy
*
Yes
No
Colitis
*
Yes
No
Congenital Heart Defect
*
Yes
No
Diabetes
*
Yes
No
Difficulty Breathing
*
Yes
No
Emphysema
*
Yes
No
Epilepsy
*
Yes
No
Fainting Spells
*
Yes
No
Frequent Headaches
*
Yes
No
Glaucoma
*
Yes
No
Hay Fever
*
Yes
No
Heart Attack
*
Yes
No
Heart Murmur
*
Yes
No
Heart Surgery
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis
*
Yes
No
Herpes/Fever Blisters
*
Yes
No
High Blood Pressure
*
Yes
No
HIV pos/AIDS
*
Yes
No
Hospitalized for any reason
*
Yes
No
Kidney Problems
*
Yes
No
Liver Disease
*
Yes
No
Low Blood Pressure
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Pacemaker
*
Yes
No
Psychiatric Problems
*
Yes
No
Radiation Treatment
*
Yes
No
Rheumatic/Scarlet Fever
*
Yes
No
Seizures
*
Yes
No
Sickle Cell Disease/Traits
*
Yes
No
Sinus Problems
*
Yes
No
Stroke
*
Yes
No
Thyroid Problems
*
Yes
No
Tuberculosis (TB)
*
Yes
No
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following:
Aspirin
*
Yes
No
Codeine
*
Yes
No
Dental Anesthetics
*
Yes
No
Erythromycin
*
Yes
No
Latex
*
Yes
No
Penicillin
*
Yes
No
Tetracycline
*
Yes
No
Other - Please list any other drugs/materials that you are allergic to:
Signature
Date
Date Format: MM slash DD slash YYYY
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