Cosmetic Dentist Long Island for implants, dentures, crowns, veneers

MEDICAL INFORMATION FORM

Name:		Date:
Email:
Physicians Name:		Phone:
Physicians Address:

Have you had any major illnesses, surgery or hospitalization?
Do you take any drugs or medications?

Are you allergic to penicillin?		No YES
Are you allergic to Latex/Rubber?		No YES
Do you have any other allergies?		No YES
Have you been asked to take an antibiotic prior to receiving dental treatment?		No YES

Please check any of the following which you have had or have at the present time:

	Abnormal Bleeding		Heart Attack
	AIDS		Heart Murmur
	Anemia		Hepatitis A (Infectious)
	Angina		Hepatitis B (Serum)
	Artificial Heart Valve		MVP
	Artificial Joint/Limb		Osteoporosis
	Asthma		Pacemaker
	Cancer		Prolapsed Valve
	Chemotherapy		Radiation Therapy
	Diabetes		Rheumatic Fever
	Drug Dependency		Sinus Trouble
	Emphysema		Stroke
	Epilepsy		Thyroid Disease
	Fainting Tendency		Tuberculosis
	Hi Blood Pressure

Do you have any disease, condition or medical situation not listed above?

Women: Are you pregnant now or think you may be pregnant? No YES

PLEASE INFORM THE OFFICE IF THERE IS ANY CHANGE IN YOUR HEALTH OR MEDICATIONS

Terry S. Shapiro, D.M.D.
Restorative and Cosmetic Dentistry
20 Old Post Road
East Setauket, NY 11733
631.751.4433
drshapiro@drterryshapiro.com

Terry S. Shapiro, D.M.D.
20 Old Post Road
East Setauket, NY 11733

drshapiro@drterryshapiro.com

Long Island dentist practicing general and cosmetic dentistry - dentures, implants, crowns, veneers - in East Setauket, New York, serving Port Jefferson - Coram - Selden - Holbrook - Ronkonkoma - Holtsvile - Middle Island - Lake Grove - Centereach - Patchogue - Smithtown and Stony Brook. Providing quality dental care in Suffolk County for over 20 years.

Home About Us Cosmetic Dentistry Family Dentistry Testimonials Before and After For New Patients Contact Blog Links Site Map
powered by: register.com