TELL US ABOUT YOURSELF

Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental
Care. Please fill out this form in ink. If you have any
Questions or need assistance, please ask-we will be happy to help.




Today's date
Day of birth
Last Name
Middle Name
First Name
Home Phone Work Phone Cell Phone
E-mail address
Address
City State Zip code
Person to contact in case of emergency Phone
Whom may we thank for referring you?  
 
Your General Dentist's name Phone
Patient's Employer Ocupation
Spouse or Parent's name Employer
The Patient is under 18 years or the patients is insured or you are not the patient      Yes      No

TELL US ABOUT YOUR HEALTH

How would you rate your health?
When did you have your last physical exam?
If you are under the care of a physician, please give reason(s) for treatment:
Physician’s Name Telephone Number
Are you presently taking any medication including over the counter vitamins or herbal supplements?      Yes      No

Have you ever been hospitalized or had surgery?      Yes      No


Do you have heart trouble or cardiovascular disease?      Yes      No

Do you have damaged or artificial heart valves?      Yes      No

Do you have a cardiac pacemaker?      Yes      No

Do you take aspirin routinely?      Yes      No

Have you ever had any trouble with prolonged bleeding?      Yes      No

Have you ever been treated for a tumor or cancer?      Yes      No

Please explain:
Have you been told to take antibiotics before dental treatments?      Yes      No

Mitral Valve Prolapse (MVP)

   Yes    No

Heart Murmur

   Yes    No

Rheumatic Fever

   Yes    No

Angina

   Yes    No

Arteriosclerosis

   Yes    No

High Blood Pressure

   Yes    No

Low Blood Pressure

   Yes    No

Anemia

   Yes    No

Kidney Disease

   Yes    No

Migraine

   Yes    No

Thyroid Disease

   Yes    No

Asthma

   Yes    No

Lung Disease

   Yes    No

Tuberculosis

   Yes    No

Liver Disease

   Yes    No

Hepatitis

   Yes    No

Diabetes

   Yes    No

Glaucoma

   Yes    No

Venereal Disease

   Yes    No

Infectious Diseases

   Yes    No

Ulcers

   Yes    No

Cancer

   Yes    No

Radiation Therapy

   Yes    No

Chemotherapy

   Yes    No

HIV/AIDS

   Yes    No

Mental Disorders

   Yes    No

Seizures

   Yes    No

Epilepsy

   Yes    No

Stroke

   Yes    No

Drug Dependency

   Yes    No

Alcoholism

   Yes    No

Do you have any diseases, syndromes, symptoms or other medical problems not mentioned above? If so, explain
Do you smoke?      Yes      No

Female      Male

Today I feel:
I certify that I have read and understood the above information. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information, including the diagnosis and the records of any treatment of examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners.
Patient Signature or Guardian/Parent if minor

TELL US ABOUT YOU AND YOUR TEETH

1. How long has it been since your last cleaning?
2. Have you lost any teeth in the last year?      Yes      No

3. Have you ever had orthodontic treatment (braces)?      Yes      No

4. Have you ever been treated for gum disease?      Yes      No

5. Do you have any lumps in or near your mouth?      Yes      No

6. Have you had any head, neck, jaw, or teeth injuries?      Yes      No

7. Do you suffer anxiety before or during dental visits?      Yes      No

8. Have you ever been sedated for dental treatment?      Yes      No

Your Chief Complaint

TELL US ABOUT YOUR SYMPTOMS

Are you experiencing pain at this time?      Yes      No

Do you grind your teeth?      Yes      No

Do you wear a night guard?      Yes      No

Has a filling or crown been placed on this tooth recently?      Yes      No

Prior to this appointment, has root canal therapy been initiated on this tooth?      Yes      No

Have you ever had a root canal done before?      Yes      No

Is there anything else we should know about your teeth, gums or sinuses that would assist us in our diagnosis?
Is there anything you would like to tell us in order to make your experience more comfortable?
Patient Signature: date



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WHAT YOU SHOULD KNOW AND DO BEFORE-AFTER YOUR VISIT

PRE-VISIT RECOMMENDATIONS

We want to take the best care of you and your health. To do so, we will need some medical information from you. Also in an effort to serve you in the best and fastest way, we will need additional information and give you recommendations that you should follow.

Medical information: Please prepare a list of all medications, whether prescribed or not, to provide us, with the name of the medication, the dosage and the frequency you take it.

Please call prior to your appointment to let us know if you are taking any antibiotic pre-medication because of MVP, heart murmur, cardiac or any body prosthetic or rheumatic heart disease, and any other reason.

Please have handy the name and phone number of your family doctor and cardiologist, if applicable, as they may be of use to us.

Additional information: Please make sure that you bring your referral slip with you so we can have a great communication with your General Dentist.

If you are under 18 or your child is, a parent or legal guardian must accompany him or her.

Please carry with you your insurance information (name of company, address, group number, S.S.N. of insured…) and your card so we can file for you your claim right away.

POST-OPERATIVE CARE

Once you become our patient, we totally commit ourselves to you and your dental health. We will take care of you before, during and after your treatment.

Even after you leave our office, we will keep on taking care of you. We will recommend you the best at home care so you will benefit from the highest level of comfort. We will remain at your entire disposal for any further questions whether by phone or at our office. Please do call us at 305 604 8876.

Six months after treatment, we will call you to perform a follow-up visit. The purpose of this visit is, when necessary, to confirm that your tooth and body are healing as anticipated. Patients heal in different ways so it is important to us to keep track of our most complex cases. Please, note that this visit is totally free and will include one or more x-rays.

When your treatment at Elite Endodontics is finished, it is very important for your health and your tooth that you contact your restorative dentist to schedule an appointment. We offer you to do so at our office or you can do it on your own. This should be done in the next few weeks following your endodontic therapy to ensure its success.

If you wish to read about specific post-operative care, please click here.


WE ARE LOCATED AT:

407 Lincoln Rd
Suite 11-G
Miami Beach, Fl 33139

305 604 8876

rootcanaldr@elite-endo.com

*for directions and more information please click the map

We are very sensitive and respectful of your time and we will always see you at your scheduled time. Should a complex case or an emergency delay us, it will only take a few minutes of your time and we will of course dedicate you our undivided attention for your whole treatment. We hope that the following hours and days will fit your schedule. Your convenience is very important to us.
You will find us at the office as follows:

Monday-Friday

9:00 a.m. to 6:00 p.m.

CALL US NOW TO SCHEDULE YOUR APPOINTMENT AT

305 604 8876