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Dentist Federal Triangle | 955 L’Enfant Plaza SW Suite 1205, Washington DC, DC 20024, US | (202) 488-8300

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Dentist Federal Triangle

955 L’Enfant Plaza SW Suite 1205,
Washington, DC, DC 20024, US

(202) 488-8300

Monday: 7:30 am – 4:00 pm
Tuesday: 7:30 am – 4:00 pm
Wednesday: 7:30 am – 4:00 pm
Thursday: 7:30 am – 4:00 pm
Friday: Closed
Saturday: Closed
Sunday: Closed

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Dental News in Federal Triangle DC

Dentist Federal Triangle

March 15, 2023

Tobacco & Your Teeth: The Risks of Chewing and Smoking | Best Dentist Federal Triangle

Chewing and smoking tobacco are known to cause severe health problems, particularly in the lungs. But the risks to your mouth and teeth can be just as extensive and alarming. If you use tobacco, stop. Here’s what tobacco can do to your oral health. Chewing Tobacco According to the Academy of General Dentistry (AGD), tobacco […]
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March 1, 2023

Are You Brushing Your Teeth Properly? | Federal Triangle Dentist

Many people are surprised to learn that, for years, they have actually been brushing their teeth the wrong way. Brushing your teeth the wrong way may cause oral health problems. Learn how to brush your teeth the right way and you will protect them for many years to come. The common way people brush their […]
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February 15, 2023

Gum Health and Alzheimer’s Disease | 20024 Dentist

Your gum health may have an impact on your cognitive function. One recent study found a correlation between gum disease and increased cognitive decline for people living with early stages of Alzheimer’s disease. While more studies are needed to make a definitive connection, this study illustrates the importance of continuing the conversation about oral health […]
Read More >>

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Medical History

First Name *

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Are you currently being treated by a physician for a specific condition?
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If so, please tell us about your treatment

Have you recently been hospitalized or had a major operation?
YesNo

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Have you ever had a serious head or neck injury?
YesNo

If so, please tell us about the head/neck injury

Are you taking any medications, pills, or drugs?
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Please list all medications and dosage

Are you on a special diet?
YesNo

Please tell us about your diet

Do you use tobacco?
YesNo

Please tell us how often and what type of tobacco consumption

Recreational drug and/or alcohol use, combined with local anesthesia may cause a life-threatening emergency.

Have you ever been advised that you require antibiotics prior to a dental appointment?
YesNo

Please tell us about the antibiotics

Do you take, or have you taken, PhenFen or Redux?
YesNo

If so, please tell us about your PhenFen/Redux usage

Have you ever taken Fosomax, Boniva, Actonel or any other medications containing bisphosphonates?
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If so, please tell us about your bisphosphonate usage

Have you recently used controlled substances?
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If so, please tell us which controlled substances and amount/frequency

Have you recently consumed alcohol?
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Please tell how much alcohol and how recently

Women (Please check all that apply)
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Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *
AspirinAcrylicErythromycinIodineLatexLocalAnestheticsMetalNovocaineNitrousOxidePenicillinSulfaDrugsTetracyclineValiumXylocaineNone of the AboveOther
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Do you have, or have you ever had any of the following medical conditions? (Please select all that apply) *
AnemiaChemotherapyColdSores/FeverBlistersCortisoneMedicationExcessiveBleedingFrequent CoughFrequent HeadachesHay FeverHemophiliaHigh Blood PressureHives or RashKidney ProblemsLiver DiseaseParathyroid DiseaseRecent Weight LossRheumatismShinglesSpina BifidaStrokeThyroid DiseaseVenereal DiseaseArthritis or GoutBlood DiseaseBruise EasilyCongenital Heart ProblemsDiabetesDrug/Alcohol AddictionEmphysemaFrequent UrinationHeart MurmurHeart Valve or PacemakerHerpesHypoglycemiaLung DiseaseRheumatic FeverTuberculosisUlcers or GI ProblemsAsthmaChest PainsConvulsionsEasily WindedExcessive ThirstFrequent DiarrheaGenital HerpesHeart Attack/Heart FailureHepatitis (B or C)Low Blood PressureIrregular HeartbeatLeukemiaMitral Valve ProlapseRadiation TreatmentsRenal DiseaseScarlet FeverSickle Cell DiseaseStomach/Intestinal DiseaseSwelling of LimbsTonsillitisYellow JaundiceArtificial JointBlood TransfusionCancerCurrently PregnantDizziness or FaintingEating DisorderEpilepsy or SeizuresGlaucomaHeart TroubleHepatitis (A)HIV-AIDS-ARCJaw Joint PainPsychiatric CareSinus ProblemsTumor or GrowthX-ray/ChemotherapyNo to All

Do you have any condition or problem, not listed, which we should know about? Please explain

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

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Patient Information

First Name *

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Marital Status *
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If the patient is not a minor, please disregard this section

Who does the patient live with?
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If the patient is the responsible party, please disregard this section

Relationship to Patient

First Name

Last Name

Preferred Name

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SSN

Sex

Email Address

Address

City
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State / Province

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Phone Number

Alt. Phone Number

Employer

Employer Phone Number

Emergency Contact

Emergency Contact Name *

Relationship to Patient *

Address *

City *
Error: Country and State Field Must be available.

State / Province *

Zip / Postal Code *

Phone Number *

Alt. Phone Number *

Referral Information

Please share with us how you heard about our office. Thank you. *
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Signature *

Your health and safety always rank #1 with us.

You’ll notice a few differences when you visit, but the care you receive won’t be one of them. Here are a few things you’ll see:

We will use no-touch mobile communications such as text, email and phone.
Hand sanitizer is readily available.
We’re using some new protective gear.
If you’re not feeling well, we can help you reschedule.

There are also a few things behind the scenes that might not stand out. Just a few include:

Added cleaning and disinfection of public spaces.
Continued strict sterilization monitoring.
More training than required on protective measures

Did we mention that we’re excited to see you? But before we do, please take a minute to fill out the pre-appointment screening and health history forms by clicking below! Thank you.

COVID-19 Pre-Screen Questionnaire

First Name *

Last Name *

Contact Phone Number *

Email Address

Do you or have you had a fever of above 100 degrees in the past three days? *
NoYes

Have you recently lost or had a reduction in your senses of smell or taste? *
NoYes

Do you have a sore throat? *
NoYes

Do you have a dry cough? *
NoYes

Do you have a runny nose? *
NoYes

Have you been in contact with someone who has tested positive for or suspected they were positive for Covid-19 (corona virus?) in the last two weeks? *
NoYes

Have you tested positive for Covid-19 or are you awaiting test results for Covid-19 within the last 10 days? *
NoYes

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