Skip to content
2307 Davisson Run Rd., Suite 201, Clarksburg, WV 26301 •
(304) 622-4949
Facebook-f
Home
Dental Services
General & Family
Forms
Contact Us
Menu
Home
Dental Services
General & Family
Forms
Contact Us
Dental Forms
- Frank W. Angotti, D.D.S.
Forms coming soon.
Patient Registration
Patient's Name
*
Date of Birth
*
Sex
*
If a minor, name of legal guardian
Home Phone
Mobile Phone
*
Work Phone
Mailing Address
*
City
*
State
*
Zip
*
Employer
*
Whom may we thank for referring you to our office?
INSURANCE INFORMATION
Not covered by dental insurance
Member ID#
Dental Insurance Co.
Group Number
Claims Address
Covered by spouse's insurance?
Yes
No
Spouse's Name
Spouse's dental insurance company
Group Number
Spouse's birthday
Do you have, or have you had any of the following?
(Please check any that apply)
Are you required to Pre-medicate before any dental treatment?
Blood problems (Anemia)
Blood transfusion
Heart problems
Heart murmur, mitral valve prolapse, heart defect
Heart pacemaker
Stroke
Artificial joints or valves
Any metals placed in body e.g. Screws, plates, rods
High blood pressure
Low blood pressure
Tuberculosis or other lung problems
Kidney disease
Hepatitis, jaundice or other liver disease
Diabetes Type 1
Diabetes Type 2
Epilepsy or Neurological disorders
Thyroid problems
Arthritis
Herpes or cold sores
AIDS or HIV positive
Cancer/Tumor
Abnormal bleeding after any surgery
Hayfever or sinus trouble
Allergies or Asthma
Are you allergic to, or have you reacted adversely to any of the following?
*
Latex
Penicillin or other antibiotics
Local anesthetics
Codeine or other narcotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Other
Other
Are you taking any of the following?
Aspirin
Anticoagulants (blood thinners e.g. Coumadin)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Nitroglycerin
Osteoporosis (bone density) medicine
List all medications currently
List all medications currently
Women
*
Are you pregnant or plan to become pregnant
Taking hormones or contraceptives
Do you smoke, vape or use tobacco?
Yes
No
Name of Patient/Gaurdian
*
Today's Date
*
Submit
Contact Form
Name*
*
Address*
*
Phone*
*
Email*
*
Message/Comments*
*
SUBMIT