Junction West Dental Patient Form JunctionWest Dental Patient Form Your Name(Required) First Name Last Name Preferred Name Preferred First Name Preferred Last Name Your Email Address(Required) Birthday MM slash DD slash YYYY Marital StatusPlease SelectSingleSeparatedDivorcedWidow/edGenderPlease SelectMaleFemaleOtherCell Phone(Required)Your Address Street Address Address Line 2 City Postal / Zip Code Date of your last dental visit MM slash DD slash YYYY Reason for visitDo you suffer from dental anxiety? Yes No Dental Anxiety Scale ( 1-10 )Please Select12345678910Do you suffer from allergies? Yes No Explain what it isHealth Information None Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis HIV High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Respiratory Problems Radiation Treatment Rheumatic Fever Rheumatism Sinus Problems Other Please list any medications you are currently takingHave you ever had any complications following dental treatment?(Required) Yes No Have you been admitted to a hospital or needed emergency care during the past two years?(Required) Yes No Are you now under the care of a physician?(Required) Yes No Write the physician informationDo you have any health problems that need further clarification?(Required) Yes No Explain what it isDo you have Dental Insurance?(Required) Yes No Do you have secondary Dental Insurance?(Required) Yes No How were you referred to our office? Google Flyer Facebook Instagram Opencare Existing patient Other Write the patients nameFollow us on Instagram kingwestdentalI have read and agree to the terms of use(Required) I agree to the privacy policy.Please read the full TERMS OF USE before signing.EmailThis field is for validation purposes and should be left unchanged.
