Westfield Oral Surgery Associates, P.C.
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1 Westfield Oral Surgery Associates, P.C. Philip R. Geron, D.M.D., F.A.A.O.M.S. Bord Certified A.D.S.M. #3102 Diplomate, American Board of Orofacial Pain, Diplomate, American Board of Pain Mangement 320 Lenox Avenue, Westfield NJ Telephone: (908) Fax: (908) HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching a diagnosis. Please take your time and answer each question as completely and honestly as possible. Please sign each page. TODAY S DATE PATIENT INFORMATION MR. MS. MISS MRS. DR. NAME: First Middle Initial Last Age: Birth Date: Male Female Address: City/State/Zip: Employed By: Address: SS#: Home Phone: Work Phone: Cell Phone: Marital Status: Single Married Widowed Divorced Other Responsible Party: Family Dentist: Address Family Physician Address Referred By: HEALTH INSURANCE (Complete even if you are covered by auto insurance) Insured Insured s Soc. Sec. No. Relationship Insured s Birth date Insured s Address City State Zip Insurance Co. Adjuster (not agent) Phone No. Insurance Billing Address City, State, Zip Policy No Group No. I.D. No. If you have additional insurance, please enter the information on the reverse side of this form. Patient Signature Date
2 Do you have or have you had any of the following complaints? 1. Face or Jaw Pain 2. Jaw noises (clicking, popping, grinding) 3. Jaw catching or locking open 4. Inability to open mouth fully or comfortably 5. Headaches 6. Visual disturbances 7. Eye pain 8. Ear pain 9. Neck soreness 10. Shoulder soreness 11. Sinus problems 12. Tooth pain 13. Ear buzzing 14. Burning mouth/tongue 15. Teeth grinding 16. Snoring List any medications/substances which have caused an allergic reaction: List any medications currently being taken: List any treatments you have had for this problem and all health professionals you are currently seeing: Practitioner Specialty Treatment & approximate date SYMPTOMS: PLEASE INDICATE LOCATION AND TYPE OF ANY HEAD PAIN
3 HISTORY OF SYMPTOMS: What do you believe is the cause of your pain or condition? If accident, date Motor vehicle accident Motorcycle accident Work related incident Playground incident Athletic endeavor Fight Fall Accident FAMILY HISTORY Have any members of your family (blood kin) had: arthritis migraines headaches Illness Injury Unknown Other SOCIAL HISTORY Occupation Do you have children? Y N If yes, how many children? Y N Are you currently under unusual stress? Y N Do you chew tobacco? Y N Recent changes in lifestyle? Y N Do you exercise regularly Number of caffeine drinks per day What are their ages? Y N Do you smoke? Alcohol consumption Number of Packs Cigarettes per Day Week Occasional Social Drinker Daily None
4 MEDICAL HISTORY (Please indicate dates on questions checked YES) Y N Adenoids Removed Y N Tonsils Removed Y N Anemia Y N Arteriosclerosis Y N Asthma Y N Autoimmune disorders Y N Bleeding easily Y N Blood pressure High Low Y N Bruising easily Y N Cancer Y N Chemotherapy Y N Chronic fatigue Y N Cold hands & feet Y N Current pregnancy Y N Depression Y N Diabetes Y N Difficulty concentrating Y N Dizziness Y N Emphysema Y N Epilepsy Y N Excessive thirst Y N Fluid retention Y N Frequent cough Y N Frequent illnesses Y N Frequent stressful situations Y N General anesthesia Y N Glaucoma Y N Gout Y N Hay fever Y N Hearing impairment Y N Heart murmur Y N Heart disorder Y N Heart pacemaker Y N Heart palpitations Y N Heart valve replacement Y N Hemophilia Y N Hepatitis Y N Hypoglycemia Y N Immune system disorder Y N Injury to: Y N Face Y N Neck Y N Mouth Y N Teeth Y N Insomnia Y N Intestinal disorders Y N Jaw joint surgery Y N Kidney problems Y N Liver disease Y N Meniere s disease Y N Menstrual cramps Y N Multiple sclerosis Y N Muscle aches Y N Muscle shaking (tremors) Y N Other Y N Muscle spasms or cramps Y N Muscular dystrophy Y N Needing extra pillows to help breathing at night Y N Nervous system irritability Y N Nervousness Y N Neuralgia Y N Osteoarthritis Y N Osteoporosis Y N Ovarian cysts Y N Parkinson s disease Y N Poor circulation Y N Prior orthodontic treatment Y N Psychiatric care Y N Radiation treatment Y N Rheumatic fever Y N Rheumatoid arthritis Y N Scarlet fever Y N Shortness of breath Y N Sinus problems Y N Skin disorder Y N Slow healing sores Y N Speech difficulties Y N Stroke Y N Swollen, stiff or painful joints Y N Tendency for: Y N Frequent Colds Y N Ear Infections Y N Sore Throats Y N Tired muscles Y N Tuberculosis Y N Tumors Y N Urinary disorders Y N Wisdom teeth (Third Molar) extraction
5 Westfield Oral Surgery Associates, P.C. FINANCIAL AGREEMENT AND RESPONSIBILITY A. I, the undersigned, have insurance with (insurance company) and assign directly to Dr. Philip Geron or Westfield Oral Surgery Associates, all benefits, if any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges, whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. Deductibles or co-payments, if applicable, must be made at the time of service. If patient overpayment is made based on pre-determination or pre-authorization estimates, patient reimbursement will be made once insurance payments are made. SIGNATURE: DATE: B. FINANCIAL AGREEMENT Please be advised, that Westfield Oral Surgery does not represent any insurance carrier, nor is Westfield Oral surgery responsible for any determinations made by your insurance. Insurance policies are agreements between the patient and the insurance carrier. It is the patient s responsibility to understand their policies and guidelines as to covered and non-covered procedures. I acknowledge that payment is due at the time of treatment, unless other arrangements have been made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance plans. Estimated fees for services will be provided upon request after examination. If payment cannot be made in full at the time of service, any fees still not paid within 30 days of service will be subject to a 1.5% monthly interest and all legal/collection costs will be the patient s/guardian s responsibility. Once all patient balances are cleared and a patient credit is determined, a refund, if any, can be processed. SIGNATURE: DATE: C. MINOR/CHILD CONSENT I, (parent/guardian) being the parent of (child s name) do hereby request and authorize the staff to perform the necessary services for my child, including examinations, x-rays, administration of appropriate anesthetics which are deemed advisable by the doctor. SIGNATURE: DATE: D. Westfield Oral Surgery strives to protect your privacy. We are required by law to: Maintain the privacy of protected health information Give you access to this notice of our legal duties and privacy practices regarding health information about you Follow the terms of our notice that is currently in effect A copy of the HIPAA Privacy Policy is available at the front desk for your review. SIGNATURE: DATE:
Georgia Knotek D.D.S. Personalized Dental Care
Georgia Knotek D.D.S. Personalized Dental Care Name: Social Security #: Date of birth: Age: Sex: M / F Phone: Home/Cell Address: City: State: Zip Code: Email: Occupation: Employer: Business Phone: Physician:
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Spouse s Name Spouse s Employer Emergency Contact Name: Phone: Relationship:
247 River Vista Place Suite 200 Twin Falls, Idaho 83301 www.twinfallssmiles.com (208) 734-8080 PATIENT REGISTRATION Name: Preferred Name: Address: Home Phone: Work Phone: Cell Phone: Email: Can we contact
PATIENT INFORMATION. SPOUSE INFORMATION (if applicable) Home phone (if diff.): Cell phone: Work phone:
PATIENT INFORMATION Full name: Preferred name: Home address: Home phone: City/State/ZIP: Cell phone: Social Security #:_ Sex: M F Date of birth: Marital status: married single divorced widowed E-mail address:
NAME AND PHONE NUMBER OF PHARMACY:
Emil W. Tetzner, D.M.D., M.S. Practice Limited to Periodontics *Please complete both sides AND MAIL BACK TO OUR OFFICE* Name Street City & State Zip Code Home Phone Business Phone Cell E-Mail Birth Date
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
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New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
PLEASE FILL IN ALL INFORMATION COMPLETELY CITY STATE ZIP HOME PHONE # CELL # DATE OF BIRTH: YOUR EMPLOYER PHONE # HOW DID YOU HEAR ABOUT US?
205-661-2201 3713 Mary Taylor Road Birmingham, AL 35235 Date: PLEASE FILL IN ALL INFORMATION COMPLETELY NAME ADDRESS CITY STATE ZIP HOME PHONE # CELL # WORK # EMAIL DATE OF BIRTH: SEX SELECT ONE: SINGLE
Welcome. Patient Name: Social Security #: (Last name) (First name) (Middle Initial) Street Address City State Zip
Welcome Thank you for choosing us for your dental care needs. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to contact us. (206)
Dr. Víctor Vergara DMD P.A Livingston Rd, Bldg # 100, Ste. #106, Naples, FL Fax PATIENT HEALTH RECORD
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Patient Information. Health Information
Patient Information Patient Name: Date: Last First MI (Preferred name) Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): Ext: Cell: Email: Address: Street Apartment
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
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CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
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Candace L. Peterson, DMD PATIENT REGISTRATION Date A. Responsible Party SS # - - Last First Middle Home Address Birthdate E-mail City State Zip Code Home Phone ( ) - Cell Phone ( ) - Work Phone ( ) - Employer
PERSONAL INFORMATION
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PATIENT REGISTRATION
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PATIENT REGISTRATION
TIME 2:51 PM DATE 6/26/2013 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?
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Primary Insurance Information
Durell Family Den-stry Welcome We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we'll be glad to help you.
PATIENT REGISTRATION
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PATIENT REGISTRATION
ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred Name: Last Name: Middle
Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Address
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Has a family member been a patient in our office? Yes No
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Whom do we thank for referring you?
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PATIENT REGISTRATION
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The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in
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Personal Information Last Name First Name Pref. Name MI Mailing Address Apt # City State Zip Home# ( ) Cell# ( ) Sex: M F E-Mail: Confirmation of Apts by Email? Yes No Date of Birth / / SSN#: Marital Status:
DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS OR CONCERNS? (Circle all correct responses)
Name How do you wish to be addressed of Birth Reason for today s visit Former dentist Reason for leaving of last dental visit Reason for last dental visit How often do you brush? How often do you floss?
Take a few minutes to answer the following questions so we can better serve you with your dental needs. P a t i e n t I n f o r m a t i o n
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Dental Registration and History
~) Patient Information (PLEASE PRINT) ftj. Dental Insurance Date Who is responsible for this account? SS/HIC/Patient ID # Relationship to Patient. Patient Name----,------,--,-, Last Name Insurance Co.
Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:
PATIENT INFORMATION Today s : / / Patient Name (Last, Middle, First) Social Security #: Male / Female: of Birth: / / Street Address: Email Address: Home Phone: Mobile Phone: Work Phone: IF THE PATIENT
Responsible Party Information
Patient Information Date Male Female Married Single Divorced Separated Student Last Name First Name Middle Address City State Zip E-mail Address Social Security # Date of Birth Home # Work # Cell # Employer
What types of care are you most interested in? Please check all that apply: Cleaning Crowns Implants Braces Dentures Teeth bleaching Pain relief
Client Information Name Preferred Name Address Birthdate City, Zip Code S.S.N Home Phone Work Phone Cell Employer Occupation Location May we contact you at work? Yes No When is the best time to contact
❶ PATIENT INFORMATION: ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? ❸ RESPONSIBLE PARTY INFORMATION: PATIENT SIGNATURE DATE
❶ PATIENT INFORMATION: DATE WORK PHONE PATIENT S NAME ADDRESS HOME PHONE EMAIL BIRTH DATE AGE CELL PHONE GENDER: MALE FEMALE ❷ WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE? FAMILY / FRIEND NAME OFFICE
Patient Registration
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Patient Information. Patient Name: ( ) Last Name, First Middle Preferred Name
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Welcome. Name Perferred name Last First MI Mr Mrs Ms Dr Birthdate Social Security Number Single Married Divorced Widowed
Welcome Thank you for choosing to visit our dental office. It is our pleasure to meet you! In order to serve you best, please take a moment to provide us with some important information. Your responses
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
LONDON BRIDGE SMILES Patient Information (please print) Name Social Sec. # Date of Birth Male/Female First MI Last Address City State Zip Home Phone Cell Phone E-mail Employer Occupation Work Phone Business
WELCOME! Patient Information:
WELCOME! Patient Information: 10220 Medlock Bridge Rd. Suite 100 Johns Creek, Ga. 30097 Name: Last First MI Mailing Address: Phone #: (C) (W) (Other) Date of Birth: SSN: Sex: Male Female Marital Status:
WELCOME PATIENT INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE
WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we ll be glad to help you. We look forward to working
Acknowledgment of Receipt of Notice
Acknowledgment of Receipt of Notice patient acknowledgment I acknowledge receipt of a copy of Maximum Mobility s Notice of Privacy Practices with an effective of January 1, 2012. printed name of patient
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
Patient Information. Dental Insurance. Emergency Contact
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Patient Information. Date: Last First MI
1320 South Lapeer Road Lake Orion, Michigan 48360 (248) 693-6213 Patient Information Patient Name: Date: Last First MI Male Female Married Single Child Other Birth Date: Social Security #: Driver s License
Responsible Party Information
3521 COMMERCE CT APPLETON, WI 54911 (920)-734-7730 WELCOME TO OUR PRACTICE Patient Name Preferred Name (Last Name) (First Name) (MI) Gender: Male / Female Family Status: Minor / Single / Married / Other
Patient Registration
Patient Registration Date: First Name Last Name Middle Initial Preferred Name E-mail Patient Information Address City State Zip Home Phone Cell Phone Work Phone Ext Birthdate Age Social Security Drivers
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed?
PATIENT LAST NAME: FIRST: INITIAL: How do you wish to be addressed? Address City State Zip Telephone (Mobile) (Work) (Home) Email How did you hear about our practice? INSURANCE INFORMATION Primary Insurance
PATIENT REGISTRATION FORM Account #:
PATIENT REGISTRATION FORM Account #: All forms must be completed and signed prior to treatment. GENERAL INFORMATION Patient Name: First Middle Last Address: Home Phone No: Work Phone No: Cell Phone No:
Your Physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain:
Dental History Medical History Reason for today s visit: _ Former Dentist:_ Date of last dental visit_ Date of last dental x-rays_ Mark Yes or No to indicate if you presently have or previously had any
Patient Registration PATIENTS WITH DENTAL INSURANCE ALL THIS INFORMATION IS NECESSARY TO VERIFY YOUR DENTAL COVERAGE!!
Patient Registration Patient Name Date of Birth Age If child, Parent's name: Mr. Mrs. Ms. Dr. I prefer to be called Single Married Divorced Widowed M F Address City St Zip. Home Phone( ) Cell Phone( )
Patient Information. Male Female Married Single Child Other. Health Information
Patient Name Patient Information Last, First MI (Preferred Name) D ate: Social Security #: Birth Date: Driver s Lic #: Cell phone Phone (Home): (Work): Ext: Address: Street Apartment # City State Zip Code
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
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JOHN R. SIMPSON, D.D.S, M.D., F.A.C.S.
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Patient Information:
Patient Information: Today s Date: Name: Preferred Name: Date of Birth: / / Age: SS# Driver License# Home Address: City Zip Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email: Employer Address
Name: Last First Middle. Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Street City State Zip
PATIENT INFORMATION Name: E-mail: Gender: Male Female Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Address: Date of Birth: / / Social Security Number: - - Driver s License #: RESPONSIBLE PARTY INFORMATION
# A St, Surrey, BC V3R 4H6 Ph# Fax#
#200-10203 152A St, Surrey, BC V3R 4H6 Ph# 604-589-2212 E-mail: office@guildfordorthodontics.com Fax# 604-589-2269 Name Age Sex Date of Birth Last First Address Tel# Street City Postal Code School Grade
PATIENT REGISTRATION
TIME 10:44 AM DATE 7/12/2011 ID: Chart ID: First Name: Patient Is: Policy Holder Responsible Party Responsible Party (if someone other than the patient) First Name: PATIENT REGISTRATION Last Name: Preferred
Dell A. Goodrick, DDS, FAGD
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Acknowledgement of Receipt of Notice of Privacy Practices
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Firewheel Smiles corn
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Patient Registration Form
Patient Registration Form Patient Name: Date of Birth: SS #: Driver s License: Address: City/State/Zip: Name of Insured: Insured SS#: Insured DOB: Relation to Patient: Spouse Parent Other Employer: Position
Address Who referred you to our practice? relationship
Health History Form Date Name Home Phone ( ) Cell ( ) Work ( ) Address City State Zip Code Occupation Height Weight Date of Birth Sex M F SS# Emergency Contact Relationship Phone ( ) E-mail Address Who
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last) Birth Date: Age: Race/Ethnicity: Sex: Male Female
Patient s Full Name: (First) (Middle) (Last) Birth Date: Age: Race/Ethnicity: Sex: Male Female Marital Status: Single Married Divorced Widowed SS #: Address: City: State: ZIP: Email: Mobile #: Work #:
Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information
Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient
WELCOME TO OUR PRACTICE
Chart# WELCOME TO OUR PRACTICE On behalf of entire team at A Great Smile Dental, let me welcome you to our practice. We are grateful that you have chosen us to meet your dental needs, and trust that you
Jeffrey R. Wert, D.M.D., P.C.
Jeffrey R. Wert, D.M.D., P.C. Patient Registration Form Date: Patient Name: Birthdate: Sex: M F Address: Email Address: Home Phone: SSN: - - Marital Status: S M D W Cell Phone: Employer: Work Phone: Ext:
Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:
Today s : Name: Nickname: Male Female Birthdate: / / SS#: Email: Home #: Work #: Cell #: Best Time to Contact You: Preferred Method of Contact: Please choose all that apply. Home Work Cell Text Email Address:
Patient Information. Date: Last First MI
1320 South Lapeer Road Lake Orion, Michigan 48360 (248) 693-6213 Patient Information Patient Name: Date: Last First MI Male Female Married Single Child Other Birth Date: Social Security #: Driver s License
PATIENT INFORMATION. Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address:
PATIENT INFORMATION Name: Last First Middle Initial Nickname D.O.B. Social Security#: Marital Status: Sex: Male or Female Address: City: State: Zip Code: Employment Status: Employer: Employer Address:
1590 West Street Road, Warminster, PA Ph: (215) Fax: (215) Patient Information.
1590 West Street Road, Warminster, PA 18974 Ph: (215)957-0700 Fax: (215)957-0703 www.bucksdental.com Patient Name: Patient Information Last First Mi Date: Male Female Married Single Child Other Social
HARTSELLE FAMILY DENTISTRY, LLC PATIENT REGISTRATION
HARTSELLE FAMILY DENTISTRY, LLC 256-773-0800 PATIENT REGISTRATION Maggie McKelvey, D.M.D Ashley Holladay, D.M.D Patient Information First Name: Last Name: Address: Address 2: City: State: Zip Code: Home
YOUR CHILD'S PERSONAL INFORMATION. RESPONSIBLE PARTY (Person responsible for Child's Account)
Thank you for selecting our team for your dental care. We are pleased to welcome you to our practice! To help us better serve you and meet your dental healthcare needs, please complete the following forms.
Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other
Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages
Thomas Yoon Dental Patient Information. Health Information
Patient Name: Thomas Yoon Dental Patient Information Last First MI (Preferred Name) Social Security #: Date of Birth: / / Gender: Male Female Marital status: Phone # (Home): (Cell): (Work): Ext: E-mail
538 SAVANNAH HIGHWAY CHARLESTON, SC (843)
DENTAL HISTORY Name: Reason for today s visit: Previous dentist: Previous dentist s phone number: Date of last dental care: Last dental x-rays: Please indicate any of the following issues that apply with