J North Dental Hygiene Form

Client Information

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

Emergency Contact

Add another emergency contact

Insurance Information

Insurance Company

Name of insurance policy holder

Birthday of policy holder

Policy/plan number

Subscriber # or ID #

Medical History

Do you have any of the following allergies?

Aspirin

Benzocaine

Codeine

Hay Fever

Latex

Local anesthetic

Penicillin

Other

Please elaborate below

None

Is there anything else regarding your medical history that we should be aware of?

Please list Medications with reason, dosage and frequency

Do you require Premedication / antibiotics before dental treatment?

Dental History

Date of last dental cleaning

Date of last dental exam

Date of last dental x-rays

Are you currently experiencing any of the following?

Tooth pain or discomfort while chewing

Grinding or clenching teeth

Bleeding gums

TMJ pain

Sensitivity (hot, cold and/or sweet)

Please elaborate below

None

Do you have or have you ever had any of the following?

Dentures

Braces

Periodontal (gum) treatments

Implants

Wisdom teeth extraction

None

Is there anything else regarding your dental treatment that we should be aware of?

Patient name or Guardian

Date

I understand that at least 6 feet of space, hard flooring, a utility sink or bathroom for cleaning up must be near by.

I understand J North Dental Hygiene does NOT take x-rays and I will need to have them done yearly to confirm no infection or decay is present in areas that cannot be examined by J North Dental Hygiene.

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