We want to thank the people of Roanoke Rapids who helped us through the tornado catastrophe and we look forward to serving our loyal patients for years to come!


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PATIENT INFORMATION (STEP 1 OF 2)

Fields denoted by asterisk (*) are required.
First Name*
Last Name*
Middle Name
Social Security #*
Birth Date*
Email Address*
Phone (Home)*
Phone (Work)
Phone (Cell)
Address*
City*
State*
Zip Code*
Date of Last Dental Visit*
Reason for Visit*

Have you ever been diagnosed or experienced any of the following? Check all that apply:
AIDS Growths Pregnancy
Due Date:
Allergies
If yes, list:
Hay Fever Radiation Treatment
Anemia Head Injuries Respiratory Problems
Arthritis Heart Disease Rheumatic Fever
Artificial Joints Heart Murmur Rheumatism
Asthma Hepatitis Sinus Problems
Blood Disease High Blood Pressure Stomach Problems
Cancer Jaundice Stroke
Diabetes Kidney Disease Tuberculosis
Dizziness Liver Disease Tumors
Epilepsy Low Blood Pressure Ulcers
Excessive Bleeding Mental Disorders Venereal Disease
Fainting Nervous Disorders Codeine Allergy
Glaucoma Pacemaker Penicillin Allergy

Have you ever had any complications following dental treatment?

Yes. If yes. explain:

Have you been admitted to a hospital or needed Emergency care during the past two years?

Yes. If yes. explain:

Are you currently under the care of a Physician?

Yes. Name of physician: Please explain:

Are you currently taking any medications?

Yes. If yes, please list medications:

To the best of my knowledge, all of the preceding answers and information provided are true and correct.
Upon any changes to my health, I will inform the doctors at my next appointment.



© 2012 THE DENTAL OFFICES OF HOWARD YEE, DMD, PA