New Patient Form | Dr Toomey

First name

Address

Email Address

Last name

DOB

Marital Status

Single

Married

Divorced

Widowed

Cell

Work

Home

Emergency Contact

Emergency Contact Phone

How did you hear about us?

Are you happy with your smile?

Yes

If No, Why?

Has you physician told you to pre-medicate w/antibiotics, prior to dental work?

Yes

Are you taking biophosphate drugs? (ie: Fosamax, Actonel, Boniva)

Yes

Are you on a daily regimen of aspirin?

Yes

Are you taking Coumadin or other blood thinners?

Yes

If yes, how many days prior to dental appointments, did your Dr tell you to stop it?

Have you had any surgeries in the last year?

Yes

If yes, list surgery and approximate date

Do you have any conditions NOT listed above?

Drug Allergies

Food/Latex Allergies

Women: Are you pregnant?

Yes

Approximate Date of Last Menstrual Cycle

List all medications you currently take (prescription AND over-the-counter)

Medication

Strength/mg

Frequency per day

Primary Care Physician

Phone