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  • English (US)
  • Periodontal Patient Information Questionnaire

  • Coast Periodontics & Laser Surgery
    Lynn C. Sayre-Carstairs, DMD, Inc.
    info@coastperiodontics.com

     

    You information is safe! The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

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  • Oral History


  • Health History

  • Have you ever experienced a reaction to any of the following?



  • Have you ever had?





  • Clear
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  • Clear
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  • (For Office Use Only)

    Clinical Information

  • Examination:

  • Diagnosis

  • Occlusion

  • Should be Empty: