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Magicland Dental of Pacoima
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Patient Information
LocationId
Primary Language
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English
Spanish
Gender
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Female
Marital Status
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Single
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First Name
Middle Name
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Allow Texting?
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Home Phone
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Preferred method of communication
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Home Phone
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Cell Phone
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Date of Birth
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Responsible Party
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Relationship to patient
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Self
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Spouse
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First Name
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Patient Work Information
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How Long? (Months)
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Emergency Contact
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Relationship to patient
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Patient Physician's Name
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Smile Evaluation
1.
Would you like to change something in the appearance of your smile?
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Yes
No
If yes, Explain
2.
Are your teeth not aligned (straight)?
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Yes
No
If yes, Explain
3.
Are any of your teeth Chipped, Protruding, Hidden?
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Yes
No
4.
Do you have spaces that you don’t like?
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Yes
No
If yes, Explain
5.
Would you like to brighten the color of your teeth?
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Yes
No
If yes, Explain
6.
What would you like to change the most about the appearances of your Teeth?
Agree and Continue
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