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Patient Form

Patient Registration

Basic Information
Dental History
Appliance (Bridge/Denture/Partial)? Yes No
Medical History
Good Health? Yes No
Serious Illness or Operations? Yes No
Blood transfusion? Yes No   Weight loss medicine? Yes No
Habits: Smoke Yes No   Drugs Yes No   Tobacco Yes No
Prolonged bleeding? Yes No
If yes: Operation Injury Extraction
Family History: Diabetes Heart Problem Tumors
Women: Pregnant Nursing Birth Control Pills
Medical Conditions
AIDS/HIV Cancer Diabetes Asthma Heart Problems High BP Thyroid
Stroke Ulcer Tuberculosis Hepatitis Kidney Disease Liver Problems Mental Disorder
Upload your signature of patient (PNG, JPG)
Contact Information
Emergency Contact
Basic Information
Dental History
Appliance (Bridge/Denture/Partial)? Yes No
Medical History
Good Health? Yes No
Serious Illness or Operations? Yes No
Blood transfusion? Yes No   Weight loss medicine? Yes No
Habits: Smoke Yes No   Drugs Yes No   Tobacco Yes No
Prolonged bleeding? Yes No
If yes: Operation Injury Extraction
Family History: Diabetes Heart Problem Tumors
Women: Pregnant Nursing Birth Control Pills
Medical Conditions
AIDS/HIV Cancer Diabetes Asthma Heart Problems High BP Thyroid
Stroke Ulcer Tuberculosis Hepatitis Kidney Disease Liver Problems Mental Disorder
Upload your signature of patient (PNG, JPG)
Contact Information
Emergency Contact