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We'll Take Good Care Of You
HOME
Your Treatment Plan
Our Pledge To You
Smile Gallery
Savings Plan
About Us
About Alexandria Smiles
Payment Options
We'll Take Good Care Of You
Careers
Blog
Contact
1400 Hawthorne Street, Suite 3, Alexandria
320-421-0096
Schedule an Appointment
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
Preferred day(s) of the week for an appointment?
*
Any Day
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred time(s) for an appointment?
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Any Time
Morning
Noon
Afternoon
Evening
Best time(s) to call?
Morning
Noon
Afternoon
Evening
Are you a current patient?
Yes
No
Please describe the nature of your appointment
(e.g., consultation, check-up, etc.)
Thank you!
Please fill out and submit the medical/dental history form below before your first visit.
Medical / Dental History
Medical / Dental History Form
Patient's Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Last Visit
MM
DD
YYYY
Email
Birth Date
MM
DD
YYYY
Marital Status
Primary Dental Guarantor
Secondary Dental Guarantor
Patient Employed by
Spouse's Name
Spouse Employed by
Who may we thank for referring you here?
Person responsible for this account
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Physician Name OR Clinic Name
Pharmacy
Sex
Male
Female
If female, please answer the following
check all that apply
Taking birth control pills
Pregnant
Nursing
If pregnant, # of weeks
Do you smoke or use tobacco?
Yes
No
Conditions
Please check all that apply
Abnormal Bleeding
Allergies
Alzheimer's Disease
Anemia
Angina Pectoris
Arthritis
Artificial Bones
Artificial Heart Valve
Asthma
Blood Transfusion
Bruise Easily
Cancer-Chemotherapy
Chest Pain
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Excessive Thirst / Dry Mouth
Fainting Spells
Frequent Headaches
HIV+ AIDS
Hay Fever
Heart Attack
Heart Murmur / Irregular Heartbeat
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous / Anxious
Pace Maker
Pneumocystitis
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Sensitive Teeth
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Trouble Sleeping
Tuberculosis
Ulcers
Allergies
Please check all that apply
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Medications
Please list any medications you are currently taking.
Other Diseases, Conditions or Problems
Is there any disease, condition, or problem that you think this office should know about that is not covered above? Please describe below.
DENTAL HISTORY
Are you having dental pain or discomfort at this time!
Yes
No
Do you feel nervous about having dental treatment?
Yes
No
Have you ever had a bad experience in a dental office?
Yes
No
Last Dental Visit, and Services Performed
Do you wear removable partial or complete dentures?
Yes
No
Have you lost teeth?
Yes
No
If yes, why?
Complications with extractions
How often do you brush
How often do you floss or use other aids?
Do you experience:
Please check any that apply
Bleedings gums
Food collects between teeth
Unpleasant taste
Teeth sensitive to sweets
Teeth sensitive to extreme temperatures
Teeth sensitive when chewing
Do you feel you have good teeth?
Are you pleased with your smile? If no, why not?
Thank you!
