King Studio Patient Form
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Your Name
(Required)
First Name
Last Name
Preferred Name
Preferred First Name
Preferred Last Name
Your Email Address
(Required)
Birthday
MM slash DD slash YYYY
Marital Status
Please Select
Single
Separated
Divorced
Widow/ed
Gender
Please Select
Male
Female
Other
Cell Phone
(Required)
Your Address
Street Address
Address Line 2
City
Postal / Zip Code
Date of your last dental visit
MM slash DD slash YYYY
Reason for visit
Do you suffer from dental anxiety?
Yes
No
Dental Anxiety Scale ( 1-10 )
Please Select
1
2
3
4
5
6
7
8
9
10
Do you suffer from allergies?
Yes
No
Explain what it is
Health Information
None
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
HIV
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Pregnancy
Respiratory Problems
Radiation Treatment
Rheumatic Fever
Rheumatism
Sinus Problems
Other
Please list any medications you are currently taking
Have you ever had any complications following dental treatment?
(Required)
Yes
No
Have you been admitted to a hospital or needed emergency care during the past two years?
(Required)
Yes
No
Are you now under the care of a physician?
(Required)
Yes
No
Write the physician information
Do you have any health problems that need further clarification?
(Required)
Yes
No
Explain what it is
Do you have Dental Insurance?
(Required)
Yes
No
Do you have secondary Dental Insurance?
(Required)
Yes
No
How were you referred to our office?
Google
Flyer
Facebook
Instagram
Opencare
Existing patient
Other
Write the patients name
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kingwestdental
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