Patient Info

Thank you for selecting Wind City Dental to provide dental care for you and your family. So that we may better serve you, please complete the questionnaire below. Only complete the questionnaire if you have been directed to do so by one of our staff. If you have not been asked contact us by the schedule an appointment form.

We are the sole owners of the information collected on this site. We will not sell or rent this information to anyone. We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request.

Please enter the following information into the form, and press the "Submit" button at the bottom of the page. This information is transmitted safely and securely protected for your confidentiality.

I consent to Wind City Dental using my cell phone number to call or text regarding appointments for treatment, insurance, and my account. I understand that I can withdraw my consent at any time if I provide a number for a landline.

Responsible Party / Billing Information

Same as Above:

Insurance Information

Yes
No

Medical History

Yes
No
Aspirin Codeine Valium
Local Anesthetic Sulfa Drugs Tetracycline
Penicillin Erythromycin
Latex
 
Arthritis or Gout Artificial Joint Asthma Allergies / Hay Fever Autoimmune Disease Bleeding Problem or Anemia Blood disease Blood Transfusion Bruise Easily Cancer Cold Sores Congenital Heart Problems Currently Pregnant Diabetes Dizziness or Fainting Drug/Alcohol Addiction Eating Disorder Emotional Problems / Anxiety / Depression
Emphysema Epilepsy or Seizures Fever Blisters Frequent Thirst Frequent Urination Glaucoma Head Injury Heart Attack or Stroke Heart Murmur Heart Trouble Heart Valve or Pacemaker Hepatitis Herpes Low Blood Pressure High Blood Pressure
HIV-AIDS-ARC Hypoglycemia Jaw Joint Pain Kidney or Liver Disease Lung Disease Migraines / Severe Headaches Psychiatric Care Radiation/Chemotherapy Rheumatic Fever Sinus Problems STD Thyroid Problems Tuberculosis Tumor or Growth Ulcers or G.I. Problems Use / Used Recreational Drugs Use Tobacco
 
Yes
No
Yes
No
I've completed it to the best of my ability
I do not have any conditions, medications, or allergies to report

Dental History

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Nearest Relative

Appointments

Morning Afternoon Either