Pradnya Dental care centre

Dr. pradnya vithhal shinde

Reg. num : A-23130

B.D.S. (MUHS)

PATIENT RECORD FORM

Patient first name__________ middle________sirname_______ DOB_______

Age___ Sex______telephone/mobile______________

Patient address_____________________________________________________

_________________________________________________city_________

Parent/guardians name: __________________________________

Occupation: ____________________________employer_____________work phone___________

Address:___________________________________________city______state_____zip_______

Reference person to contact___________________________mobile___________________

Medical history

Health quality: good (square boxes tak), fair, poor, allergies, food ,drug,heyfever,asthama, other

As the patient had any Of the following: (please tick)

Diabetes frequent headaches heart deases blood pressure high /low

Bleeding gums grinding of teeth mouth breathing

Hemophila Latex sensitivity AIDS/HIV

List drugs regularly taken & reason:___________________________________________________

Dental history

Last dental visit:____________dental work being done now?_______ IF YES EXPLAIN_____________

Has patient ever received a blow to the teeth or jaw?_____ IF YES EXPLAIN:_______________________

Has the patient has orthodontic treatment or evalution?_________IF YES, BY WHOM?______________

Informed consent

I certify that I have answered above questions to the best of my ability. I will not hold PRADNYA DENTAL
CARE CENTRE or any member of its staff responsible for error or omission that I may have made in the
completion of this form & will take full financial responsibility for any and all records taken, and will pay
the cost of X-rays and records taken at the time of consultation and/or diagnosis. I am responsible for
any negligence in maintenance of nay prostheses delivered to me

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Signature of patient (parent or guardian if patient is a minor) date: