New Patient Dental & Medical History - Lux Smiles Dental

JAI H. SHIN, DDS, PLLC
& Associates (AKA Lux Smiles)

7 Gramercy Park West
New York, NY 10003
+1 (212) 777-7126

This online form is primarily for print only, so you can:

Fill out information online, print out the completed form, and sign it at our office; or
Print out a blank form, fill it out and sign it at our office; or
Fill out the forms that we have in the office and sign there.

DENTAL & MEDICAL HISTORY

1. DENTAL HISTORY

Reason for today's visit

Date of last dental care

Date of last dental x-rays

Former Dentist's Name

Prefix First Middle Last Suffix

Former Dentist Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Check if you have had problems with any of the following:

How often do you floss?

How often do you brush?

2. MEDICAL HISTORY

Physician's Name

Prefix First Middle Last Suffix

Date of last visit

Have you had any serious illnesses or operations?

Yes
No

If "Yes" please describe:

Have you ever had a blood transfusion?

Yes
No

If "Yes" give approximate dates:

(Women) Are you pregnant?

Yes
No

(Women) Are you nursing?

Yes
No

(Women) Are you taking birth control pills?

Yes
No

Check if you have or have had any of the following:

3. MEDICATIONS

List medications you are currently taking:

Pharmacy Name

Pharmacy Phone

4. ALLERGIES

Check what you are allergic to:

Other Allergy(ies)

5. SIGNATURE

The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Signature

Date of signature

Printed name

JAI H. SHIN, DDS, PLLC & Associates (AKA Lux Smiles)