Patient Questionnaire Forms

Focusing On Seniors and Children

Teeth Implant and Invisalign Specialists

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Patient Questionnaire

Franklin Dental Patient Questionnaire

Family Owned | 28+ Years of Experience | Locally Operated

Family Owned
28+ Years of Experience
Locally Operated

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Patient Questionnaire

Free Text

Last

First

Middle

Preferred Name

Patient Birthdate*

Are you taking any prescription medications?*

Yes

No

Please list any prescribed medications and dosage

Please list your Medical Doctor's name and phone number *

Are you taking any over the counter supplements? *

Yes

No

Please list ALL over the counter supplements (ex: Ginko, Ginseng, Aspirin, Garlic)

New Field:

Yes

No

Please list all medication, latex or metal allergies

Have you ever had an adverse reaction to dental anesthetic? *

Yes

No

New Field:

Yes

No

New Field:

Yes

No

If yes, please list what you are being treated for.

Have you been hospitalized for anything MAJOR in the past 3 years? *

Yes

No

Please list what you were hospitalized for.

Women- Are you pregnant?

Yes

No

New Field:

Yes

No

If you have any artificial joints, when were they placed?

Have you ever had a heart valve replacement?*

Do you have any bleeding disorders? *

Yes

No

New Field:

Yes

No

If yes, please indicate when & for what

Do you have a pacemaker? *

Yes

No

Do you have or have you been diagnosed with Diabetes? *

Yes

No

If so, what type & when was last date & results of your A1C test.

New Field:

Yes

No

New Field:

Yes

No

Do you get cold sores? *

Yes

No

Have you ever been diagnosed with TB? *

Yes

No

Do you smoke? *

Yes

No

If so, how much?

Are there any other health concerns or diagnoses? *

Yes

No

If so, please list

Do you consume more than 3 alcoholic beverages per day? *

Yes

No

Field label

*I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree that if my balance runs over 30 days past billing date, I am responsible for any late charges that may acrue not to exceed 12% annually.

Thank you for contacting us.
We will get back to you as soon as possible.

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VISIT US

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HOURS

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HOURS

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Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

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CONTACT US

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