Skip to content
Call Us:
(330)-727-0520
Services
Find a Center
Contact Us
Book an Appointment Now
Find a Center
Book an Appointment
Call Us: (330)-727-0520
Services
Contact Us
URGENT CARE DENTIST
Book an Appointment
Step Form
PATIENT INFORMATION
First Name
Middle Name
Last Name
Home Phone
Work Phone
Cell Phone
DOB
Sex
Male
Female
SS#
Previous
Next
Patient Health History
Do you have a history of:
Do you have a history of:
No
Yes
A.I.D.S/HIV Positive
Alcoholism
Allergies
Anemia
Arthritis
Do you have a history of:
No
Yes
Excessive Bleeding
Epilepsy
Glaucoma
Hay fever
Head injuries
Do you have a history of:
No
Yes
Jaundice
Kidney Disease
Kidney Dialysis
Latex Sensitivity
Lupus
Do you have a history of:
No
Yes
Respiratory Problems/Disorders
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures/Fainting spells
Previous
Next
Medical Questions
List any medications you are taking including nonprescription drugs:
Are you allergic to any medications? If yes, please list below:
Do you have any disease/problem you think we should know about?
Have you had a transplant operation that has depressed your immune system?
Yes
No
Have you had an allergic reaction to Bananas?
Do you smoke or chew tobacco?
Have you had Heart Surgery?
Are you now under the care of an MD?
Are you taking or have you ever taken bisphosphonates? (Fosamax or Actonel for osteoporosis, chemotherapy, etc)
Previous
Next
Select Service
Select Service
24/7 emergency exam
$
211.00
Select Service
Previous
Proceed to Payment
Scroll to Top
Contact Us
Contact Form Demo
Your Name
Email
Phone Number
Your Message
Submit Form
