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3033 Lauderdale Dr, Richmond, VA 23233
(804) 364 1696
Schedule an Appointment
Home
About Us
Meet the Doctor
Meet the Staff
Dental Services
Bonding and Fillings
Checkup & Cleanings
Clear Aligners
Crowns and Bridges
Crowns for Dental Implants
Porcelain Veneers
Removable Partials and Dentures
Sealants
For Patients
New Patients
Existing Patients
Dental Insurance
Accepted Insurance
Financing Option
Contact
Home
About Us
Meet the Doctor
Meet the Staff
Dental Services
Bonding and Fillings
Checkup & Cleanings
Clear Aligners
Crowns and Bridges
Crowns for Dental Implants
Porcelain Veneers
Removable Partials and Dentures
Sealants
For Patients
New Patients
Existing Patients
Dental Insurance
Accepted Insurance
Financing Option
Contact
3033 Lauderdale Dr, Richmond, VA 23233
(804) 364 1696
Home
About Us
Meet the Doctor
Meet the Staff
Dental Services
Bonding and Fillings
Checkup & Cleanings
Clear Aligners
Crowns and Bridges
Crowns for Dental Implants
Porcelain Veneers
Removable Partials and Dentures
Sealants
For Patients
New Patients
Existing Patients
Dental Insurance
Accepted Insurance
Financing Option
Contact
Home
About Us
Meet the Doctor
Meet the Staff
Dental Services
Bonding and Fillings
Checkup & Cleanings
Clear Aligners
Crowns and Bridges
Crowns for Dental Implants
Porcelain Veneers
Removable Partials and Dentures
Sealants
For Patients
New Patients
Existing Patients
Dental Insurance
Accepted Insurance
Financing Option
Contact
Patient Information
First Name
*
Last Name
*
Have you had a name change?
Yes
No
First Name
*
Last Name
*
Social Security Number
*
Date of Birth
*
Sex
*
Male
Female
Other
For Women Only
Currently Pregnant
Nursing
Are you breastfeeding?
Yes
No
Marital Status
*
Single
Married
Dependent Child
Other
Home Address
*
City
*
State/Province
*
ZIP / Postal Code
*
Email
*
Landline
Cell Phone
*
Driver's License Number
Do you have a new Dental Insurance?
Yes
No
Insured's Name
*
Insured's Employer
*
Insured's DOB
*
Insurance Co
*
Insurance Co Address
*
City
*
State/Province
*
ZIP / Postal Code
*
Insurance Phone
*
Subscriber ID
*
Group
Do you have a Secondary Dental Insurance?
Yes
No
Insured's Name
*
Insured's Employer
*
Insured's DOB
*
Insurance Co
*
Insurance Co Address
*
City
*
State/Province
*
ZIP / Postal Code
*
Insurance Phone
*
Subscriber ID
*
Group
Do you have any medical conditions we need to be aware of?
Yes
No
Cancer
Yes
No
Type
Chemotherapy
Radiation Therapy
In Remission
Cardiovascular
Angina(chest pain)
Artificial Heart Valve
Heart Attack
Heart Murmur
Heart Surgery
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Pacemaker
Rheumatic Fever
Scarlet Fever
Stroke
Yes
No
Endocrinology
Diabetes
Hepatitis A/B/C
Jaundice
Kidney Disease
Liver Disease
Thyroid Disease
Gastrointestinal
Ulcers (Stomach)
Gastrointestinal Disease
Celiac Disease
Hematology/ Lymphatic
Anemia
Blood Disorders
Bruises Easily
Excessive Bleeding
Musculoskeletal
Arthritis
Artificial Joints
Jaw Joint Pain
Rheumatoid Arthritis
Neurological
Anxiety
Depression
Diizziness
Drug/Alcohol Addiction
Fainting
Seizures
Psychiatric Illness
Respiratory
Asthma
Emphysema
Respiratory Problems
Sinus Problems
Sleep Apnea
Tuberculosis
Viral Infections
AIDS
HIV Positive
HPV
Are you taking any medications?
Yes
No
Medical Allergies
Antibiotics(Ex: Amoxicillian, Clindamycin)
Pain Pelievers (Ex: Oxycodone, Tylenol 3)
Latex
Local Anesthetics
NSAIDs
Others
Local Anesthetics (ex. Novocain)
Barbiturates
Aspirin
Penicillin or other Antibiotics
Sedatives
Latex'
Sulfa Drugs
Iodine
Other
Joint Replacement?
Yes
No
Please Explain
Other Allergies
Do you have allergies or sensitivities to medications? Please List
What medications are you currently taking?
Submit
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