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Print this form now if you want to complete the form manually and bring it to your appointment.
You may also type in your answers and then print the form for your records at the bottom.
Patient's Full Name
Are you having discomfort at this time?
When was your last dental appointment?
What was done then?
When was your last dental cleaning?
When was your last dental x-ray?
Do you take pre-medication antibiotics before dental appointments?
Have you ever had:
Clicking or locking of the jaw
Prolonged bad breath
Sores or lumps in your mouth
Clenching or grinding of teeth
Gum (periodontal) treatment
Problems with Novocain
Loose or sore teeth
Re-occuring dry mouth
Do you have removable dentures or partial dentures?
If "Yes", please explain.
Do you currently use:
Are you happy with the appearance of your smile?
If "No", what would you like changed about your smile?
Do you have questions or comments about your dental care? Explain here, please.
Signature of Patient, Parent of a minor, or Guardian of the patient (Simply type your name here)
If you want to print the completed form for your records, you must do so BEFORE you send us the form.
Copyright 2015, Curtis Marketing Group, Inc. Do not use without written permission from Curtis Marketing Group, Inc.
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9402 November Dr
St. Joseph, MN 56374
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Curtis Marketing Group | 9402 November Drive | St. Joseph, MN 56374 | (320) 363-0210 | Fax: (320) 363-0218 |
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