Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Referring Dentist
Dentist Name
Dentist Phone
Dental History
Chief Complaint
Are you experiencing pain?
Yes
No
If yes, how long?
Previous root canal treatment?
Yes
No
Any past dental trauma?
Yes
No
Medical History
Physician Name
Are you currently under the care of a physician?
Yes
No
Current Medications
Allergies (e.g., medications, latex)
Health Conditions
Heart Disease
High Blood Pressure
Diabetes
Asthma
Bleeding Problems
Smoking
Pregnancy
Other
Additional Notes or Concerns