Welcome to Jeff Velasquez, DDS
New Patient Form - Dental & Medical Info

Please check any corresponding box/es that may apply, fill out this form and submit. [Privacy Note: this file is for Velasquez Dental record only.]

Reasons for today's visit




Describe the nature of your pain or concern

Please indicate any of the following problems













Other: Specify

Do you require pre-medication




Previous Dentist

Previous Dentist phone #

Previous dentist address ( Street #, City, State & ZIP)

Last Dental visit

Last Dental x-rays

Times you brush & floss







What type of bristles do you use?





How do you rate your smile? 1-10

Are you taking any of the following medications?












Other medications:

Do you have or have you had any of the following medical problems?





























Respiratory Problems







Heart Problems










Artificial Bone/s or Joint/s








Please list any other surgeries or medical condition you have ever had :

Allergies








Other Allergies

Do you smoke






If you smoke how long & how much

Please rate your general health from 1-10:

Have you ever taken the drug Phen-fen or redux?



Do you have children? How many?

For WOMEN: Are you taking birth control pills?



For WOMEN: Are you pregnant?



For WOMEN: How far are you pregnant?

For WOMEN: Are you nursing?



Terms: (Please read and check the box)





Signature Name: (last, First MI)

Electronic Signature


Signature Date:

Enter the numbers from the image:



          
562-247-4683
541 W. Willow St, Long Beach, CA, 90806, United States
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