Dental Treatment Form

Demographic Information

Patient Information

First Name

Last Name

Date of Birth

Phone Number

Referring Doctor

First Name

Last Name

Phone Number

Treatment Information

Please Evaluate Teeth Marked

Permanent

Deciduous

Notes

Extractions

Yes

Biopsy

Yes

Apicoectomy

Yes

Tooth Exposure

Yes

I.V. Sedation

Yes

Implant

Yes

Socket Preservation

Yes

Other

Yes

If other, please specify

Patient X-Rays

Please upload patient's x-rays using the button below.

Upload a File...

0 MB/18 MB

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful information and that the doctor and their staff will rely on this information for treating the patient. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name

Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue