New Patient Form Page 10

Download a blank fillable New Patient Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete New Patient Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
Are you being/have you ever been treated for cancer of any kind? If yes, please explain:
Yes
No
Are you currently taking or have you ever taken any bisphosphonate drugs? These include: alendronate
(Fosamax), clodronate (Ostac, Bonefos), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia),
risedronate (Actonel), tiludronate (Skelid), zoledronic acid (Zometa).
Yes
No
Do you take or have you taken Phen-Fen or Redux?
Yes
No
Do you smoke or chew tobacco?
Yes
No
Do you use alcohol, cocaine, or other drugs?
Yes
No
Do you wear contact lenses?
Yes
No
Are you on a special diet?
Yes
No
Have you lost or gained more than 10 pounds in the past year?
Yes
No
Do you use more than two pillows to sleep?
Yes
No
Have you ever had any excessive bleeding requiring special treatment?
Yes
No
When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness
of breath, or feeling tired?
Yes
No
Have you been treated in a hospital in the last five years?
Yes
No
If female, please mark if you are:
Pregnant - If so, please enter your due date or week #:
Trying to get pregnant
Nursing
On birth control
Please list all current prescriptions:
Please list any other serious medical conditions, impending operations, or other medical/dental information that may possibly
affect your dental treatment:
Do you wish to talk to the dentist privately about any problems/concerns?
Yes
No
All of the above information is correct to the best of my knowledge. I understand that providing incorrect
information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of
any changes in medical status. I understand that the above information is necessary to provide me with
dental care in an efficient and safe manner. Should further information be needed, you have my permission
to ask the respective health care provider or agency, who may release information to you.
Signature (Type your name to sign electronically, or print and sign):
Date (mm/dd/yyyy):
/
/
01
01
2017
For office use:
02
02
2018
Reviewed by:
Title:
Date:
/
/
03
03
2019
01
01
2017
04
04
2020
02
02
2018
Page 10/16
05
05
2021
03
03
2019
06
06
2022
04
04
2020

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

New Patient Forms New Patient Forms Medical
New Patient Form New Patient Form Medical
New Patient Form New Patient Form Medical
New Patient Forms New Patient Forms Medical
New Patient Form New Patient Form Medical
New Patient Form New Patient Form Medical
New Patient Form New Patient Form Medical
New Patient Form New Patient Form Medical
New Patient Forms New Patient Forms Medical
New Patient Form New Patient Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 16