New Dental Patient Form

Patient Information

First name

Last name

Home phone number

Cell phone number

Email address

Date of birth

Insurance Information

Name of insurance policy holder

Policy/plan number

Dental History

Date of last dental visit

Date of last dental cleaning

Date of last dental x-rays

Please check any of the following problems that might apply to you

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding teeth or fillings

Broken teeth or fillings

Headaches, earaches, or neck pain

Jaw joint pain

Sensitivity (hot, cold and/or sweet)

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

Dentures

Braces

Periodontal (gum) treatments

Difficult extractions

Medical History

Do you have any of the following allergies?

Penicillin

Aspirin

Codeine

Latex

Local anesthetic

Percocet

Sulpha

Valium

Other

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Emergency Contact Information

Add another emergency contact

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Dr.Nader Afgan

Dr. Nader Afgan is a practicing general and cosmetic dentist in Glen Burnie, Maryland. He holds his practice to the highest standards, always staying on the forefront of dentistry's newest developments and technology. His compassionate personality makes him an ideal dentist for those needing special care.

4109699300
glenburniedentalgroup