Richmond West End / Glen Allen 804-270-7737

Family and cosmetic dentistry

We provide individualized treatment geared
toward improving your dental & overall health.

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Dental Registration and History

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    Patient Information



    malefemale




    confemails

    MinorSingleMarriedPartneredSeparatedDivorcedWidowed






    Dental Insurance





    YesNo





    Dental History







    Please place an X to indicate if you

    badbreathBad breath

    bleedinggumsBleeding gums

    lipblistersBlisters on lips or mouth

    tongueburningsensationBurning sensation on tongue

    chewmouth1sideChew on one side of mouth

    chewtobaccoChewing tobacco

    smokingCigarette, pipe, or cigar smoking

    clickingjawClicking or popping of jaw

    drymouthDry mouth

    fingernailbitingFingernail biting

    orthodonticsOrthodontic treatment

    periodontalPeriodontal treatment

    coldsensitivitySensitivity to cold

    heatsensitivitySensitivity to heat

    sweetsensitivitySensitivity to sweets

    foodcollectionbetweenteethFood collection between teeth

    soresSores or growths in mouth

    grindingteethGrinding teeth

    swollengumsGums swollen or tender

    jawpaintirednessJaw pain or tiredness

    lipbitingLip or cheek biting

    looseteethLoose teeth or broken fillings

    mouthbreathingMouth breathing

    earpainPain around ear

    Health History

    aidsAIDS/HIV

    anemiaAnemia

    arthritisArthritis, Rheumatism

    artificalheartvalveArtificial Heart Valves

    artificaljointsArtificial Joints

    asthmaAsthma

    backproblemsBack Problems

    bleedingBleeding (w/ extractions or surgery)

    blooddiseaseBlood Disease

    cancerCancer

    chemicaldependencyChemical Dependency

    chemotherapyChemotherapy

    cortisonetreatmentsCortisone Treatments

    coughCough, persistent or bloody

    diabetesDiabetes

    emphysemaEmphysema

    epilepsyEpilepsy

    faintingdizzinessFainting or Dizziness

    glaucomaGlaucoma

    headachesHeadaches

    heartmurmurHeart murmur

    heartproblemsHeart problems

    hepatitisHepatitis,

    herpesHerpes

    highbloodpressureHigh blood pressure

    jaundiceJaundice

    jawpainJaw pain

    kidneydiseaseKidney disease

    liverdiseaseLiver disease

    lowbloodpressureLow blood pressure

    mitralvalveprolapseMitral Valve Prolapse

    nervousproblemsNervous problems

    pacemakerPacemaker

    psychiatriccarePsychiatric care

    radiationtreatmentsRadiation treatments

    respiratorydiseaseRespiratory disease

    rheumaticfeverRheumatic fever

    shortnessofbreathShortness of breath

    sinustroubleSinus trouble

    skinrashSkin rash

    specialdietSpecial diet

    strokeStroke

    swollenfeetoranklesSwollen feet or ankles

    swollenneckorglandsSwollen neck glands

    thyroidproblemsThyroid problems

    tonsilitisTonsillitis

    tuberculosisTuberculosis

    tumororgrowthTumor or growth on head/neck

    ulcerUlcer

    venerealdiseaseVenereal disease

    unexplainedweightlossWeight loss, unexplained







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    Next up is the financial agreement form and last is the acknowledgement of privacy practices form. Fill out those 2 forms to finish preregistration.

    Richmond West End / Glen Allen 11551 Nuckols Road - Suite B Glen Allen, VA 23059

    Open Monday to Thursday 8AM TO 5PM

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