Gentle Dentistry of Las Colinas in Irving, Texas

Gentle Dentistry of Las Colinas

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Patient Information
  1. May we confirm this appointment by
Responsible Party
Insurance Information
  1. *At your appointment, please provide current drivers license and insurance card.
Patient Dental History
  1. If you have any specific dental problems
  2. Do you brush on a routine basis?
  3. Do you floss on a routine basis?
  4. Do your gums bleed?
  5. Does food catch between your teeth?
  6. Do you have
  7. Do you use tobacco?
  8. If you have any sores or growths in your mouth
Patient Medical History
  1. If you are now under a physicians care, please tell us
  2. If you have been hospitalized or had a major operation
  3. If you have ever had a serious head or neck injury
  4. If you are taking any medications
  5. If you are on a special diet
  6. Have you ever been treated for
  7. Women, are you
  8. Are you allergic to any of the following?




  9. Do you have, or have you had any of the following?













































  10. *Condition may require pre-medication. Call prior to your appointment.
  11. If you have any other illness not checked above
  12. TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE CORRECT. If I have any changes in my health status, or if my medications change, I shall inform the dentist and team at the next appointment.
Referral
Emergency Contact
Authorizations
  1. I hereby authorize payment directly to Gentle Dentistry of Las Colinas of the group
    insurance benefits otherwise payable to me. I understand that I am responsible for
    all costs of dental treatment. The information on this page and the dental/medical
    histories are correct to the best of my knowledge. I grant Gentle Dentistry of Las Colinas
    the right to release any information pertaining to my treatment to third party payers
    and/or health professionals.
  2. I authorize Gentle Dentistry of Las Colinas to use any photographs taken for educational and/or promotional use.