Dear New Patient,
Please allow me to welcome you into our family of patients. My team and I are honored that you have chosen us to care for your dental needs and we look forward to becoming your “partner in health”. Our practice is prevention-oriented, so you can expect your initial examination in our office to include all necessary x-rays and cancer screenings. We have learned over time that detecting problems at an early stage saves our patients valuable time and money.
We realize that you are an individual with unique preferences, therefore we will strive to tailor our approach to your needs. If you have special needs or concerns, please advise us—your input is appreciated and essential for us to serve you properly. We will also provide you with a variety of financing options from which you may choose.
We are proud of our highly trained team, each of which is carefully chosen for his or her ability to serve you in a gentle way. We appreciate the value of your time and except for emergencies in our day, you can expect us to be on time for you. We hope to receive the same courtesy from you.
Please complete the health and patient questionnaire below and click “send” at least one day before your first visit. Should you have any questions, please do not hesitate to call. All of us are looking forward to meeting you at your first visit.
Sufia Palluck, DDS
I like to be called
Marital Status S
Home Phone #
When is the best time to contact you?
Please tell us an interesting fact about yourself
Employer Zip Code
If Student, School:
Nearest friend or relative not living with you? Name:
Who may we thank for referring you?
Do You Have Dental Insurance? Yes
If yes, please provide the following information:
This insurance is through: Self
Name of Insurance Subscriber:
Insurance Subscriber's Employer:
Insurance Subscriber's SSN:
Dental Insurance Company # 1:
Insurance Phone #:
Do you have any other dental insurance coverage? Yes
Dental Insurance Company # 2:
Insurance Phone #:
I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage.
What is the reason for your visit today?
Date of last dental visit:
Last dental cleaning:
Last full mouth x-rays:
Previous dentist's name:
How often do you have examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (interplax, toothpick, etc.)
Do you have any dental problems now? Yes
If yes, please describe:
Is there anything about having dental treatment that you would like us to know? Yes
Have you ever had:
A) Orthodontic Treatment? Yes
B) Periodontal Treatment? Yes
C) Oral Surgery? Yes
Do your gums bleed or hurt? Yes
Have you ever experienced clicking or popping of the jaw? Yes
Do you experience any pain to your jaw, ear, or side of your face? Yes
Do you feel nervous about having dental treatment? Yes
If yes, what is your biggest concern:
Have you had an upsetting dental experience? Yes
Have you been under the care of a medical doctor during the past two years? Yes
If yes, for what:
Have you taken medications or drugs during the past two years? Yes
Are you taking any medications, drugs or pills now? Yes
If yes, please list name & dosage:
Are you aware of having an allergic (or adverse reaction) to any medication or substance? Yes
If yes, please list:
Indicate which of the following you have had or have at present. (Check One for Each)
Heart (surgery, disease, attack)
High Blood Pressure
Artificial Heart Valve
Mitral Valve Prolapse
Sickle Cell Disease
Do you have or have you had any disease, condition, or problem not listed? Yes
Women: Are you pregnant? Yes
If yes, Months:
Taking birth control pills? Yes
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.