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Kirkpatrick & Lai
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A family business for over 50 Years
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
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Our Story
Media
Invisalign
Testimonials
Giving Back
New Patient Forms
FAQ
Emergency
Contact Us
Locations
Tulsa
(918) 747-1346
Tahlequah
(918) 458-5050
Miami
(918) 542-1867
Okmulgee
(918) 756-5070
Let’s Talk
Schedule an Appointment!
Patient Name
*
Phone Number
*
Email
*
Comments / Questions
Dental / Medical History
Dental History
Patient Name (First & Last)
*
Dentist Name
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Armenia
Aruba
Australia
Austria
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Cook Islands
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Korea, Republic of
Kuwait
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Malawi
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Maldives
Mali
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Mayotte
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Nigeria
Niue
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Panama
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Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
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Samoa
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United States
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Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Date of Last Visit
MM slash DD slash YYYY
Reason
What concerns you most about your (or your child's) teeth?
Do you schedule regular check-ups with your dentist?
*
Yes
No
Have you ever had trauma to your mouth or teeth?
*
Yes
No
Is any part of your mouth sensitive to temperature or pressure?
*
Yes
No
Do your gums bleed when you brush?
*
Yes
No
Do you have any type of thumb/finger sucking or tongue thrusting habit?
*
Yes
No
Have you ever been examined by an orthodontist?
*
Yes
No
Has anyone in the family received orthodontic treatment?
*
Yes
No
How did they feel about the result?
Do you have any pain or soreness around your face or neck?
*
Yes
No
Are your teeth or jaws ever uncomfortable when you awaken in the morning?
*
Yes
No
Are you aware of your jaw clicking or popping?
*
Yes
No
Are you aware of grinding or clenching your teeth during the day or night?
*
Yes
No
Do you have "tension" headaches?
*
Yes
No
ALLERGIES
*
Do you have any allergic reaction to any of the following? (select all that apply)
Latex
Metals
Food (Nuts, Dairy, Wheat)
Medication
No known allergies
Medical History
Physician Name
Phone #
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
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Virginia
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Last Visit
MM slash DD slash YYYY
Please list any medications you are currently taking
*
Please list any major operations you've had
*
Have you ever been involved in a serious accident?
*
If yes, please explain
Select any of the medical conditions below that you have had or currently have:
*
HIV
Anemia
Arthritis
Asthma or Hayfever
Diabetes
Dizziness
Eating Disorders
Heart Problems
Hepatitis
Herpes
High Blood Pressure
Pregnancy
Tuberculosis
Tumor or Cancer
Venereal Disease
None
Are there any medical conditions we have not discussed that you feel we should be made aware of?
*
Signature of Responsible Party
*
I certify the above information is true and correct to the best of my knowledge.
First
Last
Signature
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