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Kyle G. Keeter, DDS ● Courtney L. Geiger, DDS ● Samuel D. Ellsworth, DDS ● MS Gabrielle C. Dizon, DDS

Patient Information

  • Last Name:
  • First Name:
  • MI:
  • Select One:
  • Dr. Mr. Mrs. Miss. Ms.
  • Preferred Name:
  • Address:
  • City:
  • State:
  • Zip:
  • Cell Phone:
  • Work:
  • Ext:
  • Home Phone:
  • Email Address:
  • DOB:
  • Social Security No:
  • Employer:
  • Position/Title:
  • No. of Yrs:
  • Spouse's Name:
  • Phone:
  • Guardian's Name (If minor):
  • Phone:
  • Emergency Contact:
  • Phone:
  • Other family members seen by us:
  • Referred by:
  • Do you have dental insurance?
  • Yes No
  • If you have dental insurance through someone else other than yourself, please provide their information below:

  • Name:
  • Employer:
  • Social Security No:
  • DOB:

MEDICAL HISTORY

  • Physician's Name:
  • Date of last exam:
  • Please list any prescription / over the counter medications you are taking:

  • Medication:
  • For:
  • Medication:
  • For:
  • Medication:
  • For:
  • Medication:
  • For:
  • Please select if you have ever had any of the following diseases or medical conditions:
    Aids Allergies Anemia
    Cancer Chemo Diabetes
    Eating disorder Epilepsy/Seizures Glaucoma
    HIV positive Heart murmur Heart problems/Chest pains
    Hepatitis A Hepatitis B Hepatitis C
    Herpes High blood pressure Kidney/Urinary problems
    Low blood pressure Mitral valve prolapse Pacemaker
    Radiation Scarlet fever Sinus problems
    Stomach/Digestive problems Stroke Ulcer
    Rheumatic fever
  • Tobacco use (what form?)
  • Yes No
  • Have you taken an oral or I.V. bisphosphonate drug? (i.e. Fosamax, Actonel, Boniva, etc.)
  • Yes No
  • Have you had a joint replacement surgery? What type?  
  • Yes No
  • Are you pregnant or nursing?
  • Please list any other medical condition(s) that we should be aware of:
  • Have you had an undesirable or allergic reaction to:
    Aspirin Dental anesthetics Latex
    Antibiotics (List)
    Pain medication(List)
    Other
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  • Name of previous dentist:
  • Date of last dental visit:
  • Have you had dental X-rays taken in the past year?
  • Yes No
  • Date of last cleaning:
  • What is the purpose of your dental visit today?
  • Do any of the following apply to you?
    Are your teeth sensitive to:
    Cold Heat Pain When Biting
    Pressure Ache Spontaneously
    Bad odor or taste Bleeding gums Discomfort in the mouth
    Dry mouth Frequent headaches Grinding or clenching
    Gum recession Have a night guard Have partials/Dentures
    Orthodontic treatment Snoring/Sleep apnea Sores or growths in mouth
    TMJ (jaw joint) problems Use CPAP/Snore Appliance
  • Is your present dental health good?
    Yes No
  • How many times a day do you brush?
  • How often do you floss?
  • Have you had previous bad experiences with dentistry?
  • What, if anything, would you change about your teeth/smile if you could?
  • Yes No
  • Are you interested in straightening your teeth?
  • Yes No
  • Do you think your teeth could be whiter?
  • Are there any concerns or topics you wish to discuss in detail?


Kyle G. Keeter, DDS ● Courtney L. Geiger, DDS ● Samuel D. Ellsworth, DDS, MS ● MS Gabrielle C. Dizon, DDS

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received a copy of Dr. Keeter / Geiger / Ellsworth / Dizon's Notice of Privacy Practices and have read and understand this information.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

By signing this form, you have reviewed and understand our Notice of Privacy Practices and give consent to use and disclose your protected health information that may be used for treatment, payment or healthcare operations.

We reserve the right to change the privacy policy as allowed by law. You have the right to revoke this consent in writing at any time and all full disclosures will then cease.

May we phone, email, or send a text to you to confirm appointment?
Yes No
May we leave a message on your answering machine at home or on your cell?
Yes No
May we discuss your dental conditions with any persons other than yourself?
Yes No

If YES, please list names below:

NAME Phone RELATIONSHIP
NAME Phone RELATIONSHIP
NAME Phone RELATIONSHIP


This consent was signed by:
Signature:
Date:
If signing on behalf of patient, please complete the following:
Personal Representative's Name:
Relationship to Patient:


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