Please fill out the easy-to-use, private, and secure intake form. It will take a few minutes to complete, but our dental team reviews this in detail to provide comprehensive care..Medical-QuestionnairesFirst NameLast NamePrefered Name / NicknamePatient Gender- Select -MaleFemaleOthersDate of BirthPrimary Phone no.Secondary Phone no.Marital Status Married Unmarried otherOccupationRetired? Yes NoDate of retirementDisability ? Yes NoDate of disabilityWho is your primary care doctor: Where is your primary care doctor located ? Phone Number of primary care doctor:allergic to any medications Yes Noallergic to any medicationsDo you smoke? Yes NoHow many years did you smoke?If you quit, when did you stop?Do you drink alcohol? What is your estimate of your general health? Excellent Good Fair PoorAny remark or comment about yourself.Submit Form