Street Address, City, & Zip *
Home Phone
Cell Phone
Work Phone
Email *
Marital Status *
Primary Dental Insurance Name
Subscriber Name & Address (if not the patient)
Subscriber Employer
Subscriber's ID #
Group #
Dental Insurance Address & Phone Number
Emergency Contact (First & Last Name)
Phone
Referred By
Name of Dentist (if you have one)
Is this visit the result of an injury?
If yes, what was the injury?
Have you previously had scaling and root planing also known as “deep cleaning” with anesthetic? If so, when?
Have you had any complication with previous dental treatment?
Do you consider yourself a nervous person when it comes to dental treatment?
Do you feel you have bad breath?
Do your gums bleed?
Have you noticed any loose teeth? If yes, how long?
Do you think your teeth are affecting your general health in any way?
Are you satisfied with the appearance of your teeth?
Do you have any sensitive teeth?
Do you have any suggestions on how we could make your periodontal treatment less stressful and more comfortable for you?
Pharmacy Name
Pharmacy Location
Pharmacy Phone #
The success of periodontal therapy is dependent on many factors including the severity of the periodontal destruction, the patient’s general physical status, and the patient’s ability and willingness to perform proper oral hygiene and stay on a recall program after active treatment. As with treatment of any complex condition, especially where drugs and surgical procedures are being used, unusual and unanticipated problems can arise, such as bleeding, prolonged numbness, sensitivity to medications, sensitive or loose teeth and pulp damage. We will make every effort to keep you informed of the treatment necessary for you. Feel free to ask questions at any time. Your involvement and understanding are very important in the long term success of your periodontal therapy. In implant surgery the potential risks and complications involved could include pain, swelling, infection, and discoloration. Numbness of the lip, tongue, chin, cheek, or tooth may occur. The exact duration may not be determinable and may be irreversible. Also possible are inflammation, injury to teeth, bleeding, bone fractures, sinus infection, and delayed healing. In some instances, implants fail and must be removed. If there is any further information that you feel we should be aware of please write it here.
Name of Primary Care
List all medical conditions you have been diagnosed with (ex: Acid Reflux, Depression, Diabetes, High BP, Osteoporosis, Thyroid Disease)
Have you had surgery or x-ray treatment for a tumor, growth, or other condition of your head, mouth, or lips?
List any serious illness or surgery you have had in the past 6 months
Have you had abnormal bleeding associated with previous surgery, tooth extraction, or trauma?
List all drugs and supplements you are taking
Have you ever been diagnosed with osteoporosis, or taken any bone altering/preserving medications (oral or IV)?
If you checked "Other drugs" above, please list them here:
Have you ever been warned against taking any drug or medicine for your own personal health?
If so, what drug and why?
Are you routinely pre-medicated with an antibiotic for a dental procedure?
What is the estimation of your general health?
Do you smoke or use smokeless tobacco (vaping)?
If so, how much?
How many years?
Have you EVER smoked or used smokeless tobacco (vaping)?
I give permission for North Raleigh Periodontics to disclose my personal health information to the following persons (spouse, sibling, parent, child, friend, doctor's office)
Patient's Full Legal Name *
Parent or Responsible Party
Relationship to Patient