Toggle navigation
About Us
New Patients
Special Offers
Refer a Patient
Reviews
Appointment
Patient Login
Refer a Patient
William Bohannan Location
Location
select
Referred By
First Name
*
Last Name
*
Email Address
*
Phone
*
Patient Info
First Name
*
Phone No.
*
Contact Info
Gender
Male
Female
Address
City
State
Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States Of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Emergency Contact Name
Emergency Phone No.
Oral Surgery
Extractions
Primary tooth chart
Main tooth chart
Implant Evaluation
Primary tooth chart
Main tooth chart
Hybrid Implants
Primary tooth chart
Main tooth chart
Lesion & Evaluation
Primary tooth chart
Main tooth chart
Exposure
Primary tooth chart
Main tooth chart
Incision & Drainage
Primary tooth chart
Main tooth chart
Biopsy
Primary tooth chart
Main tooth chart
Expose & Bond
Primary tooth chart
Main tooth chart
Bone Grafting
Primary tooth chart
Main tooth chart
Soft Tissue Grafting
Primary tooth chart
Main tooth chart
Wisdom Teeth
Primary tooth chart
Main tooth chart
Jaw Surgery
Primary tooth chart
Main tooth chart
TMJ
Primary tooth chart
Main tooth chart
Facial Reconstruction
Primary tooth chart
Main tooth chart
Facial Aesthetics
Primary tooth chart
Main tooth chart
Pathology
Primary tooth chart
Main tooth chart
Snoring & Sleep Apnea
Primary tooth chart
Main tooth chart
Extraction Third Molar
Primary tooth chart
Main tooth chart
Frenectomy
Primary tooth chart
Main tooth chart
Cosmetic Crown Lengthening
Primary tooth chart
Main tooth chart
Orthognathic Surgery
Primary tooth chart
Main tooth chart
Infection Management
Primary tooth chart
Main tooth chart
Trauma
Primary tooth chart
Main tooth chart
Other
Primary tooth chart
Main tooth chart
Pediatric Dentistry
Pediatric dentistry consultation/treatment
Primary tooth chart
Main tooth chart
Chipped/fractured tooth
Primary tooth chart
Main tooth chart
Crown
Primary tooth chart
Main tooth chart
Para-functional habits
Primary tooth chart
Main tooth chart
Orthodontic evaluation
Primary tooth chart
Main tooth chart
Missing teeth
Primary tooth chart
Main tooth chart
Special needs
Primary tooth chart
Main tooth chart
Other
Other
Primary tooth chart
Main tooth chart
Comment
Veins Clinic
Varicose Veins
Discoloration
Hx of DVT
Pain
Redness
Melasma
Swelling
Rash
Ulcers
Numbness
Onychomycosis
Post thrombotic syndrome
Other
Please state effected extremities and if any
Venous Questions
Education Spider Veins
Dental Insurance
Primary Insurance Company
Primary Insurance Company Phone
Primary Name of Insured
Primary Date of Birth
Primary Member ID
Primary Group Number
Secondary Insurance Company
Secondary Insurance Company Phone
Secondary Name of Insured
Secondary Date of Birth
Secondary Member ID
Secondary Group Number
Medical History
Are you under a physicians care right now?
Please explain
Have you ever been hospitalized or had a major operation?
Please explain
Have you ever had a serious head or neck injury?
Please explain
Are taking any medications, pills, or drugs?
Please explain
Do you take, or have you taken, Phen-Fen or Redux?
Please explain
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing biphosphonates?
Please explain
Are you on a special diet?
Please explain
Do you use tobacco?
Please explain
Do you use controlled substances?
Please explain
Are you pregnant/Trying to get pregnant(women)?
Please explain
Taking oral contraceptives(women)?
Please explain
Nursing(women)?
Please explain
Have tonsils and oor adenoids been removed?
Please explain
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
Do you have, or have you had, any of the following?
Abnormal bleeding
AIDS/HIV Positive
Alzheimer's Disease
Anemia
Angina
Are you on blood thinners
Arthritis / rheumatism
Artificial Heart Valve
Artificial Joint
Asthma
Atrial fibrillation
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cigarette, pipe, or cigar smoking
Cirulation problems
Cortisone / steroids
Cough, persistent or bloody
Convulsions
Dermal fillers
Diabetes (type)
Diarrhhea, persistent
Digestive disorder
Dizziness, fainting
Do you drink alcoholic beverages?
Do you use controlled substances ?
Emphysema / bronchitis
Epilepsy or Seizures
Excessive urination
Excessive Thirst
Glaucoma
Heart attack(date)
Heart Pacemaker
Hemophilia
Heart defect
Heart murmur / leaky valve
Hepatitis(type)
Herpes
Hiatal hernia
High or low blood pressure
HIV / AIDS
How much
Hypoglycemia
Joint replacement(knee, hip, etc)
Kidney disease
Leukemia / lymphomaLiver
Liver Disease
Lung Disease
Mitral Valve Prolapse
Neck / back problems
Osteoporosis
Pacemaker / defibrillator
Pain in Jaw Joints
Previous endocarditis
Psychiatric Care
Radiation therapy
Rheumatic or scarler fever
Shingles
Shortness of breath
Sinus infection
Stroke(date)
Sjorgren's syndrome
Stomach ulcer / hyperacidity
Swelling of feet or ankles
Swollen glands - neck
Thyroid disorder
Tuberculosis
Tumors or Growths
Valve replacement
Vision / hearing impaired
Weight loss, unexplained
List any serious illness not listed above
Please explain
Additional Information
Please explain
Dental History
Previous Dentist's Name
When was the last time you had your teeth cleaned?
Do you make regular visits to the dentist?
How often
Please explain any problems or complications with previous dental treatment?
Have any of your teeth been replaced with the following?
Fixed bridge
Removeable bridge
Denture
Implant
Do you clench or grind your teeth?
Does your jaw click or pop?
Are you experiencing any pain or soreness in the muscles of your face?
Do you have frequent headaches, neckaches or shoulder aches?
Does food get caught in your teeth?
Are any of your teeth sensitive to
Hot
Cold
Sweets
Pressure
Do your gums bleed or hurt?
When?
How often do you brush your teeth?
How often do you use dental floss?
Are any of your teeth loose, tipped, shifted or chipped?
Explain any orthodonic work you have had done?
Explain any dental work you have had done(Perio, Oral Surgery, etc.)
How do you feel about your teeth in general?
Additional Information
Date of first visit
Reason for first visit
Date of last (latest) visit
Reason for last visit
Date of next (scheduled visit)
Reason for next visit
Attached files
Attach Files
Finish
Book Appointment
I’ll choose my insurance later
Select Service
Consulting
Select Location
First Location
Fri
Mar 29
Mon
Apr 1
Tue
Apr 2
Wed
Apr 3
09:00 AM
09:15 AM
09:30 AM
09:45 AM
More
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
More
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
More
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
More
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
Pacific Standard Time