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 :


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:

541 W. Willow St, Long Beach, CA, 90806, United States
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