Eagles Landing Location
590 Eagles Landing Pkway
Stockbridge, GA 30281
678-289-2122
Jackson Location
316 West, 3rd Street
Jackson, GA 30233
770-775-0088
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*
Please provide the information of
SSN and DOB
while at the office.
Your Information:
Today’s Date:
Name:
Gender[Male Female]:
Male
Female
DOB*[Date of Birth]:
SSN*:
Address:
Email:
Home Tel #
Cell #
Employer
Whom may we thank for referring you?
Previous Dentist:
Date of last visit:
Spouse Information:
Name:
Employer:
Cell#:
SSN*:
DOB*:
Person responsible for account:
Name:
Work#
Cell#
Home#
Email:
Address:
Relationship:
SSN*:
DOB*:
Employer:
Primary Dental Insurance:
Insurance Provider:
Tel #:
Address:
ID#:
Insured’s Name:
SSN*:
DOB*:
Relationship:
Health History:
Have you had any of the following?
Heart Murmur
Yes
No
Knee replacement
Yes
No
Hip replacement
Yes
No
High Blood pressure
Yes
No
Diabetes
Yes
No
Bleeding disorders
Yes
No
Seizures
Yes
No
Hepatitis
Yes
No
Chemotherapy
Yes
No
Radiation therapy
Yes
No
HIV/AIDS
Yes
No
Please list all current medications::
Have you ever taken or do you now take:
• Blood thinner medications (Coumadin/Plavix/Aspirin) • Bisphosphonates (Fosamax/Actonel/Boniva/Zometa)
Are you Pregnant
Are you nursing
List all Allergies
Medical Doctor:
MD’s Tel #:
Secondary Dental Insurance:
Insurance Provider
Tel #:
Address:
ID#:
Group #
Insured’s Name
SSN*:
DOB*:
Relationship:
I hereby state that the information provided by me is complete and accurate and I will disclose all changes, if any, at my future visits to the office.
Primary Dental Insurance:
Signature:
Date:
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