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Patient information
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Patient's Health History
Preferred Pharmacy
Allergies
Local Anesthetics Like NovocainePenicillin or other AntibioticsSulfa DrugsBarbiturates,Sedatives or Sleeping PillsAspirinIodineAny MetalsLatex/RubberOther(please list)
Oral Health
Please check any conditions that apply to you below
Teeth grinding/clenchingMouth soresDifficulty chewing/swallowingBrokenor loose teethSensitive teethPain in jaw (TMJ)Swollen or bleeding gumsUse tobacco products
Health History
Please if you have any of the following
AlcoholismDrug AddictionRheumatic Heart Disease or Rheumatic FeverScarlet FeverHeart Trouble,Heart Attack, Or AnginaChest PainShortness of BreathPacemakerHeart SurgeryHigh/Low Blood PressureCongenital Heart ProblemSwelling of feet,ankles, handsHepatitis, Jaundice or Liver DiseaseStrokeSinus TroubleLung or Breathing ProblemsAsthma or Hay FeverHives/Skin RashFainting or Dizzy SpellsDiabetesAIDS or HIV InfectionThyroid ProblemsAllergiesArthritisJoint ReplacementStomach UlcersKidney TroubleTuberculosisPersistent CoughCough that produces bloodChemotherapy (Cancer,Leukemia)Sexually Transmitted DiseaseEpilepsy or SeizuresAnemiaGlaucomaNervousnessTonsillitisTumorsMental Health CareBack ProblemsChemical DependencyMitral Valve ProlapseCortisoneTreatmentCold Sores/Fever BlistersHypoglycemiaEating DisorderBlood Thinners
List any medications you are taking including non-prescription drugs:
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IN OHIO
1268 West Ohio Pike Amelia, OH 45102
*Select Saturday Hours Available 8AM – 1PM
At Buckeye Dental we accept All PPO’s. Additionally, we accept cash, check, Visa, Mastercard, Discover and debit cards.
