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G R E E L E Y

Endodontics

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Patient History Form

The following Patient History Form is provided for your convenience. You can fill out and submit this information online in order to save time during your visit to our offices.

Patient History Form

The following Patient History Form is provided for your convenience. You can fill out and submit this information online in order to expedite the check-in process when you arrive for your appointment to our offices.

Patient Information

First Name

Last Name

Street Address

Street Address Line 2

City

State

Zip code

Email

Date of Birth

Insurance Information

Insured First Name

Insured Last Name

Insured Date of Birth

Patient Relationship to Insured

Insurance Company Name

Insurance Company ID

Dental History

Dentist First Name

Dentist Last Name

Dentist Phone

Are you allergic to or have you had any side effects from any of the following :

Penicillin

Yes

No

Aspirin

Yes

No

Local Anesthesia

Yes

No

Other Antibiotics

Yes

No

Codeine

Yes

No

Other Medications*

Yes

No

* If "Yes" to Other Medications, please list here:

Other environmental allergies:

Do you have or have you had any of the following:

Heart Problems

Yes

No

High Blood Pressure

Yes

No

Heart Murmur

Yes

No

Bleeding Disorder

Yes

No

Arrhythmia

Yes

No

Stroke

Yes

No

Sinusitis

Yes

No

Chemotherapy

Yes

No

Tuberculosis

Yes

No

Kidney Disease

Yes

No

Low Blood Pressure

Yes

No

Rheumatic Fever

Yes

No

Mitral Valve Prolapse

Yes

No

Anemia

Yes

No

Seizure

Yes

No

Hepatitis

Yes

No

Asthma

Yes

No

Latex Allergy

Yes

No

Colitis

Yes

No

Arthritis

Yes

No

Joint Replacement

Yes

No

Immune Disorders

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Thyroid Treatment

Yes

No

Radiation Therapy

Yes

No

Diabetes

Yes

No

Other conditions not listed:

Current medications:

Recent hospitalizations:

Have you ever been told to take antibiotic premedication prior to a dental appointment?

Yes

No

For our Female Patients

Are you pregnant?

Yes

No

Are you nursing?

Yes

No

Do you use birth control pills?

Yes

No

Emergency Contact

Contact First Name

Contact Last Name

This contact is my

Contact Phone Number

Contact Email

I confirm that the information given in this form is true and correct

Thanks for submitting your Patient History Form

Endodontics

G R E E L E Y

1711 61st Ave., Suite 108 | Greeley, Colorado 80634
970-515-6332 Phone | 970-673-8923 Fax

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