Health History

Please note that this form must be filled out within 20 minutes of visiting this page.

Patient Information
Emergency Contact Information
Dental Information
 
Is your mouth dry?
Have you had periodontal (gum) treatment?
Have you had orthodontic treatment?
Have you had any problems with dental treatment?
Do you have clicking, popping or discomfort in the jaw?
Do you grind your teeth/ or wear a bruxism?


Medical Information
 
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Allergies

Aspirin Codeine Sulfa Local Anesthetic Demerol Penecilin Latex Environment

Health History
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Office policy

By submitting this form, you acknowledge and agree to our office policies for billing and cancellations:

  • Cityview Periodontal does not offer direct billing.
  • Appointment cancellations must be made within 48 hours of the appointment time.

I acknowledge and accept the above terms.