LOADING...  Please wait.
Patient`s Name*  
Dr. Ashley Starnes
Dr. Jason Bongiovi
Patient Medical History
Are you currently under the care of a physician?  
Yes No 

If yes, what is the name of the doctor/practice?  
Are you currently taking any medication?*  
Yes No 

If yes, please list them:  
Are you allergic to any medicines or food?*  
Yes No 

If yes, please list them:
  
Are you allergic to latex?*  
Yes No 

Have you ever had any surgery?  
Yes No 

If yes, please list surgeries:  
Check any of these conditions which you presently have or have previously had:
 
  Anemia 
  Ear Disorders 
  Hyperactivity 
  Premature Birth 
 
  Asthma 
  Seizure Disorders 
  Cerebral Palsy 
  Rheumatic Fever 
 
  Bleeding Problems 
  Eye Disorders 
  Kidney Disease 
  Stomach Problem 
 
  Bone Disorder 
  Autism 
  Liver Disease 
  COVID exposure 
 
  Brain Disorder 
  Heart Condition 
  Lung Disease 
  Speech Problem 
 
  Shunt 
  Heart Murmur 
  Developmental Delay 
  HIV Positive 
 
  Cancer 
  High Blood Pressure 
  Muscle Disorder 
  Pregnant 
 
  Diabetes 
  Hormone Disorder 
  Downs Syndrome 
  Nursing 
 
  Fever Blisters/ Cold Sores 
  Other conditions not listed 
 
 
Please specify for applicable conditions:  
Do you use tobacco? If so, what kind and how much?  
Do you use any other controlled substances? If yes, please explain.  
Is this your first visit to the dentist?  
Yes No 

Please list the most current dates and services performed.  
Name of former Dentist and location:*  
Date of last cleaning and exam:*  
What is your main concern about your teeth?*  
Reason for today`s visit:*  
Do you experience any unusual reactions to dental injections?*  
Have you ever had any injuries to the mouth or face area?*  
Yes No 

Additional Comments:  
I certify that the above information is accurate and complete to the best of my knowledge. I understand that any errors or omissions could harm my dental treatment and/or overall health. I will not hold Dr. Bongiovi, Dr. Starnes, or their staff responsible for the result of any errors or omissions in the information l have provided on this form.
 
Patient Signature:*  
Date*  
Reset 
Powered by Elbowspace.com