Medical & Dental History

Welcome to Divine Dental Hygiene!

Name:

Birthday

Phone # (cell)

Address (include postal code)

Email address

Name & Phone number of Guardian (if applicable)

Seniors or Special Needs or Children

When would you like an appointment?

Treatment Area (please check that you have space for me)

6 feet X 10 feet, hard flooring, sink nearby, bathroom available for clean up

Insurance (only needs to be filled out for the adults, I will add it to the kids file if needed)

Insurance Company #1

Employer

Plan Member

Members Birthday (leave blank if a patient)

Policy # or Group #

ID # or Personal #

Insurance Company #2

Employer

Plan Member

Members Birthday (leave blank if a patient)

Policy # or Group #

ID # or Personal #

Main Dental Concerns

What do you LIKE about getting your teeth cleaned?

What do you DISLIKE about getting your teeth cleaned?

Last Cleaning

Other Medical Conditions

Medications, Why, Dosage

Covid-19 Symptoms and other Communicable Diseases

If you have any of these Covid-19 or other disease symptoms, you must cancel your appointment. Please confirm that you do not have any of these symptoms prior to this first appointment.

Cough or shortness of breath
Fever or chills in the last 24 hours
Loss of taste or smell
Feeling of unwell or fatigue
Sore throat
Nausea or vomiting
Undiagnosed rash, infection or break in the skin
Communicable infectious disease (flu, cold, measles, chicken pox, or tuberculosis)
Recent exposure to COVID-19, positive case exposure
Recent travel to areas where endemic diseases are present
Recent travel out of the country in the last two weeks, without Covid-19 PCR test upon return
Tested positive for Covid-19 in the past 14 days

I confirm that I do not have any Covid-19 symptoms above.

Patient or Guardian Name

Date

I acknowledged that x-rays will not be taken by Divine Dental Hygiene. I agree to x-rays yearly to confirm that decay or infection are not present in areas that can not be examined by Divine Dental Hygiene.

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