Skip to content
Simpson Dental PLLC
(304) 342-6162
400 Allen Dr Suite 300 Charleston, WV 25302
Home
About
Meet Our Doctors
Meet Our Team
The Top 25 Women In Dentistry
Dental Lab
Upcoming Lectures
In The News
Services
General Dentistry
Bacterial Testing
Dental Bridges & Crowns
Dental Cleanings
Dental Fillings
Digital X-Rays
Panorex Panoramic X-Rays
Gum Disease
Laser Dentistry
Oral Surgery
Root Canal Therapy
Sedation Dentistry
Tooth Extractions
Cosmetic Dentistry
Dental Bonding
Dental Inlays & Onlays
Dental Veneers
Teeth Whitening
Dental Implants
Dental Implants FAQs
Implant-Supported Dentures
Dentures Overview
Implant Supported Dentures In A Day
Same Day Dentures
Advanced Technology
Orthodontics
Invisalign®
Facial Aesthetics
TempSure Envi
Botox And Fillers
Icon (IPL) Skin Treatments
PRF Microneedling
New Patients
Patient Forms
Special Offers
Gallery
Appointments
Reviews
Contact
Service Areas
X
Request An Appointment
Patient Medical Form
Patient Medical Form
Patient Name:
Birthday:
Address:
Email:
Marital Status:
SSN:
Home Ph:
Work Ph:
Cell Ph:
Dental Insurance Information
(Primary Dental Policy Holder):
Birthday:
Ins Co.
Phone No:
Member ID:
Group #:
SSN:
Employer:
Secondary Dental Policy Holder:
Ins. Co.
Phone No:
Member ID:
Group#:
Spouse:
Employer:
Medical Information
(Physician Name):
Phone No:
Pharmacy:
Phone No:
Sex:
Male
Female
If Female, Please answer by circling the following:
Are you taking birth control pills?
Male
Female
Are you pregnant?
Male
Female
Are you nursing?
Male
Female
Please answer the following:
Do you smoke or use tobacco?
Yes
No
Do you have a history of substance abuse?
Yes
No
Height
Weight
Have you ever had a sleep test or CPAP?
Yes
No
Please check all that apply to you:
Conditions:
Anemia
Abnormal Bleeding
Alcohol abuse
Artificial Heart Valve
Angina Pectoris
Colitis
Diabetes
Emphysema
Fever Blisters
Heart Attack
Hepatitis A
High Blood Pressure
Liver Disease
Psychiatric Problems
Allergies
Hay fever
Drug Abuse
Artificial Bones
Blood transfusion
Congenital Heart Defect
Difficulty Breathing
Epilepsy
Frequent Headaches
Heart Surgery
Hepatitis B
HIV-AIDS
Mitral Valve Prolepses
Pain in Jaw Joints
low blood pressure
Asthma
Arthrtics
Cancer - Chemotherapy
Cosmetic Surgery
Sleep Apnea
Fainting Spells
Glaucoma
Hemophilia
Hepatitis C
Kidney Problems
Pace Maker
Rheumatic Fever
Sickle Cell Disease
Radiation Therapy
Seizers
Shingles
Yellow Jaundice
Venereal Disease
Ulcers
Stroke
Sinus Problems
Tuberculosis
Thyroid Problems
Other
Allergies:
Aspirin
Erythromycin
Jewelry
Metals
Penicillin
Other
Codeine
Dental Anesthetics
Latex
Tetracycline
Please list all current medications:
Submit
Scroll to Top