Total Freedom Dental Implant Center 9002 E Desert Cove Ave., Suite 103, Scottsdale, AZ 85260
(480) 860-9002

Health History Info

Total Freedom Dental Implant Center believes we have assembled a truly exceptional team, one that is likely unsurpassed. Please fill in the form below or print and bring to your appointment.

Print Form

All fields marked with * are required.
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Client Information
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Dental Information
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Spouse’s Information
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Authorization / Acceptance
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Medical Information
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Medical History

Client Information

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Dental Information

Teeth Sensitive to: ColdHotSweetsPressure Dental/Oral PainBleeding GumsReceding GumsFood ImpactionClenching/Grinding of TeethBurning of TongueSwelling or Lumps in MouthFrequent Blisters on Lips or in MouthMovement or Drifting of TeethUnpleasant TasteBad BreathApprehensive about Dental TreatmentUnfavorable Dental ExperienceComplications from ExtractionsPrior Periodontal TreatmentOrthodontic TreatmentSmoke or Use TobaccoFloss DailyOral Habits: (Fingernail Biting, Cheek Biting, Etc)

Spouse’s Information

Mr.Mrs.Ms.Miss

Authorization and Acceptance

I authorize the release of treatment information, and I hereby assign any insurance benefits to the Doctor. If monthly payments are necessary, I accept the terms and conditions as described by the Doctor’s office payment plan. Should services be paid in full at the time of the treatment, and an insurance claim is filed by the Doctor’s office, payment will be directed to the Responsible Party. (Insurance payments received on accounts already paid will be forwarded to the Responsible Party.)

Medical Information

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Medical History

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The undersigned hereby authorizes Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a finance charge will be added to any overdue balance. I also assign all insurance benefits to the Doctor.
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