InstagramThis field is for validation purposes and should be left unchanged.General InformationFirst Name - Patient(Required)Middle NameLast Name - Patient(Required)Patient Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Other Email(Required) Contact InformationHome PhoneWork PhoneMobile PhonePatient Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta 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FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Mailing Address and Billing Address are the same Yes No Emergency InformationEmergency ContactEmergency Contact PhoneFamily DoctorFamily Doctor PhoneFamily Doctor Phone Ext.Other InformationSocial Security NumberOccupationEmployerDental InformationPrevious ProviderDo your gums bleed when you brush or floss? Yes No Are you currently experiencing dental pain or discomfort? Yes No Are your teeth sensitive to cold, hot, sweets, or pressure? Yes No Do you have earaches or neck pains? Yes No Does food or floss catch between your teeth? Yes No Do you have any clicking, popping, or discomfort in your jaw? Yes No Have you had any periodontal (gum) treatment? Yes No Do you grind your teeth? Yes No Have you ever had orthodontic (braces) treatment? Yes No Do you have any sores or ulcers in your mouth? Yes No Have you had any problems associated with previous dental treatment? Yes No Do you wear partial dentures? Yes No Do you wear complete dentures? Yes No Have you ever had a serious injury to your head, neck, or mouth? Yes No Medical InformationAllergiesCheck all that apply Acetaminophen/Tylenol Acrylic Aspirin Codeine Demerol Erythromycin Hay fever/seasonal Ibuprofen/Motrin/Advil Iodine Latex Local anesthetic Metals Morphine Penicillin Shellfish Sulfa Tetracycline Other Please elaborate on any reactions you have to the indicated allergiesIndicate if any of the following apply to you in either the past or present:Check all that apply Abnormal/excessive bleeding AIDS or HIV infection Alzheimer's/dementia Anemia Angina Anxiety Arteriosclerosis Arthritis Asthma Autoimmune disease Blood disease Blood Thinners Blood transfusion Breathing problems/respiratory disease Bronchitis Cancer/chemotherapy/radiation treatment Cardiovascular disease Chest pain upon exertion Chronic pain Congestive heart failure Damaged heart valves Diabetes Eating Disorder Emphysema Epilepsy Fainting spells or seizures Frequent headaches Gastrointestinal disease G.E. Reflux/persistent heartburn Glaucoma Gout Hard to Numb Hearing difficulties Heart attack Heart murmur Heart rhythm disorder Hemophilia Hepatitis, jaundice or liver disease High blood pressure Joint Replacement Kidney problems Low blood pressure Mitral valve proplapse MTHFR Neurological disorders Osteoporosis/Paget's disease Other congenital heart defects Pacemaker Pregnant (currently) Psychiatric care Recurrent infections Rheumatic fever Rheumatic heart disease Rheumatoid arthritis Severe headaches/migraines Severe or rapid weight loss Sexually transmitted infection (STI) Sinus trouble Sleep Apnea Snoring Stroke Systemic lupus erythematosus Thyroid problems TMJ Disorder Tuberculosis Tumors or growths Ulcers Other Do you have any disease, condition or problem that is not listed that you think I should know about?Preferred Pharmacy(Required)Pharmacy Phone(Required)Date of last physical exam MM slash DD slash YYYY Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No Has there been any change to your general health within the past year? Yes No Do you use tobacco (smoking, snuff, chew, bidis, vaping)? Yes No Have you had a serious illness, operation, or been hospitalized in the past 5 years? Yes No Are you wearing a nicotine patch? Yes No Are you taking any prescription or over-the-counter medicines? Yes No Do you have sleep apnea? Yes No Are you pregnant? Yes No Are you taking birth control or hormone replacement? Yes No Are you nursing? Yes No Have you ever taken FosaMaz, Boniva, Actonel, or other medications containing bisphosphonates? Yes No Please list any surgical procedures you have undergone and when they occurred.Were you referred to this office? Yes No AuthorizationI hereby authorize Spring Oaks Dental to perform any and all forms of treatment, medication, and therapy that may be indicated in connection with the dental care of the patient above, and further authorize and consent that the doctor chooses and employs such assistance as she deems fit. I also understand that prior to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or team. I also authorize Spring Oaks Dental to use photographs, radiographs, other diagnostic materials, and treatment records for the purpose of teaching, research, and scientific publications. I agree to pay for all services rendered by this office. Please read above, and understand that the information provided in this form is accurate. A truthful health history will help ensure the best possible dental treatment. The information provided here will be used by Spring Oaks Dental and patient to inform any further discussion of the patient's health prior to or during an appointment. By signing below you also acknowledge that you will not hold Dr. Klein, Dr. Buckley, Spring Oaks Dental, or any other team member responsible for any action or lack of action because of errors or omissions that may have been made during the completion of this form. Print Name(Required)The information I provided in this form is correct to the best of my knowledge(Required) I agree