Contact Us

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2080 Harper Street
Choctaw, OK, 73020
United States

Choctaw Dental: New Patient Form

Fill out the new patient form to allow Dr. Jon Clarke & his team at Choctaw Dental provide you comprehensive dental treatment in Choctaw, OK.

Name *
Name
Date of Birth
Date of Birth
Mailing Address
Mailing Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Number
Cell Number
Spouse's Phone Number
Spouse's Phone Number
Emergency Phone Number
Emergency Phone Number
Date of Birth
Date of Birth
Medical Health History
Fainting Spells, Seizures, or Epilepsy
Stroke(s)
Frequent or severe headaches
Thyroid Problems
Persistent Cough or Swollen Glands
Heart Problems
Chest Pain
Shortness of breath
Blood Pressure Problem
Heart Murmur
Heart Valve Problem
Taking heart medication
Rheumatic Fever
Pacemaker
Artificial Heart Valve
Blood Problems
Easy Bruising
Frequent Nosebleeds
Abnormal Bleeding
Blood Disease (anemia)
Every require a blood transfusion?
Allergy Problems
Hay Fever
Sinus Problems
Skin rashes
Taking Allergy Medication
Intestinal Problems
Ulcers
Weight gain or loss
Special diet
Constipation/Diarrhea
Kidney or bladder problems
During the past 12 months, have you taken...
Antibiotics or sulfa drugs
Anticoagulants (e.g., Coumadin)
High Blood Pressure Medicine
Tranquilizers
Insulin, Orinase, or similar drug
Aspirin
Digitalis or drugs for heart trouble
Nitroglycerin
Cortisone (Steroids)
Natural Remedies
Nonprescription drug/supplements
Premedications required by physician
Cancer/Tumor
Are you allergic, or have you reacted adversly to any of the following?
Local anesthetics ("Novocaine")
Penicillin or other antibiotics
Sulfa Drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Tuberculosis or other respiratory disease
Do you drink alcohol?
Do you smoke?
Hepatitis, jaundice, or liver trouble
Herpes or other STD
HIV-positive/AIDS
Glaucoma
Do you wear contact lenses?
History of head injury?
Epilepsy or other neurological disease?
History of alcohol or drug abuse?
Do you have any disease, condition, or problem not listed previously that you feel we should know about?
Are you taking contraceptives or other hormones?
Are you nursing?
Are you pregnant?
Have you reached menopause?
Date
Date