Intake Forms - Better Days Wellness Clinic

New Patient Intake

Medical Wellness

Better Days Wellness Clinic is dedicated to providing the best care and solutions to your medical wellness goals. In order to provide the highest level of service and care, please fill in the following information. Accuracy is very important, please provide the most up to date information. If you have any questions or concerns regarding the required information, please call or email so we may provide you with the support you need.

Phone: (224) 507-5195

Email: [email protected]

Complete the appropriate form for your service.

An email confirmation will be sent to the email you provide

Teeth Whitening

First Name

Last Name

Today's Date

Date of Birth

Address

City, State, Zip Code

Preferred Method of Communication

Email Cell Phone Home Phone

Occupation

Have you had any recent dental work?

Yes No

If yes, please describe:

Have you ever experienced tooth sensitivity or gum irritation after a tooth whitening treatment?

Yes No

If yes, please describe:

Are you currently pregnant or nursing?

Yes No

Are you taking any medications or supplements that may affect teeth whitening?

Yes No

If yes, please list:

Have you had any allergic reactions to dental or cosmetic products in the past?

Yes No

If yes, please describe:

If you checked any of the above, please give details:

Does anyone in your immediate family have a history of any of the following?

Any other conditions?

Do you have any allergies? If yes, please specify

Are you currently undergoing any medical treatment or taking any medications for a medical condition?

Yes No

If yes, please describe:

Have you ever had a joint replacement or other surgical procedure that required antibiotics prior to dental treatment?

Yes No

If yes, please describe:

What is your reason for seeking a tooth whitening treatment? (Check all that apply)

To improve the appearance of my smile For special occasions (wedding, graduation, etc.) To boost my confidence Other (please specify):

if you selected other, please describe.

How would you rate the current shade of your teeth on a scale of 1-10 (with 1 being the darkest and 10 being the whitest)?

Do you have any specific concerns or expectations regarding the teeth whitening treatment?

Yes No

If yes, please describe:

Are you interested in any other cosmetic dental procedures?

Yes No

If yes, please describe:

Please check the box below to validate the statements provided are true and accurate medical history.

I acknowledge that the information provided on this form is accurate and complete to the best of my knowledge. I understand that the teeth whitening treatment may not be suitable for everyone, and that the technician will determine my eligibility for the procedure based on the information provided on this form and a physical examination.

2024 | Better Days Wellness Clinic, PLLC

New Patient Intake

Medical Wellness

Complete the appropriate form for your service.

Medical Weight Loss

Medical Aesthetics

Wellness Injections

Medical Weight Loss

Wellness Injections

Medical Aesthetics

Teeth Whitening

Chemical Peel

Body Contouring

Contact

Don't know what service is best for you? Take the quiz & find out.

New Patient Intake

Medical Wellness

Complete the appropriate form for your service.

Medical Weight Loss

Medical Aesthetics

Wellness Injections

Medical Weight Loss

Wellness Injections

Medical Aesthetics

Teeth Whitening

Chemical Peel

Body Contouring

Contact

Don't know what service is best for you? Take the quiz & find out.

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