619.295.2202 • www.completedentalhealth.com
Accurate answers wil help us provide you the safest treatment experience. Al information you provide is confidential.
If you need assistance or have a question, please ask.
Patient’s Name _____________________________________________________________________________________ ____________
Your PHYSICIAN’S name and phone #Yes ❏ No ❏
Have you ever been hospitalized or had surgery?
If yes, please give year and reasons or types of operations.
Please mark YES or NO and CIRCLE any specific condition you currently have or have had previously. MEDICATIONS
Have you ever taken any of the fol owing:
Please list al prescription and over-the-counter medications you are
currently taking ___________________________________________
blood disorder, blood transfusion, sickle cel
congenital heart defects, artificial valves, endocarditis
past or present drug use including cocaine,
difficulty breathing at night, snoring, sleep apnea
do you participate in any sports __________________
Do you have any of the fol owing al ergies:
local anesthetics (novocaine, lidocaine, etc.)
aspirin, codeine, or other pain medication
hives, contact dermatitis, latex sensitivity
al ergic to any other medication ___________________
problem not listed above? _______________________
any complication with / reaction to past
how nervous does dental treatment make you:
any injury to your teeth, mouth, jaws, or head
____ not at al ____ slightly ____ moderately ____ extremely
Reason for today’s visit __________________________________
any awareness of clenching or grinding your teeth
How do you feel about the appearance of your front teeth
Previous dentists name _________________________________
Date of last dental treatment _______________
treatment. If yes, describe _____________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect
information can be very dangerous to my health. I also understand it is very important to report any changes in my medical or dental
status to the dentist at the earliest time, and I agree to do so.
AUTHORIZATION FOR USE OF IMAGE AND BIOGRAPHICAL INFORMATION
I am a patient of Dr. . I understand that my dentist may take video or still images of the work that he is doing. I consent to my dentist, or a representative of his staff, taking these images. I understand that my dentist may use my images, and biographical information that I provide to my dentist, for purposes of education, publicity, promotion and advertising. I understand that I will receive no remuneration for such use.
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Structure of the Manufacturing Business and Growth Strategy Embracing the Challenge of Opening Up New FieldsRequired by Society Taking on the Challenge of Satisfying Unmet Syrup, a treatment for iron-deficiency anemia. We also Medical Needs took over the right to manufacture and market theAlfresa Pharma Corporation, which is responsible forantidepressant agent Anafranil in January 200