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Patient Forms | Teche Dental

Patient Forms

We're excited to meet you! Please take a few minutes to fill out our New Patient Form.  You can fill out the online form to the right, or you can click here to download a PDF of our forms.

If you have any questions, we're happy to help you! Just contact our office.

Please note that this form does time out after 20 minutes, please complete in one sitting.

Sores or growths in your mouth
Sensitivity when biting
Sensitivity to sweets
Sensitivity to hot
Sensitivity to cold
Periodontal treatment
Loose teeth or broken fillings
Grinding teeth
Food collection between teeth
Clicking or popping jaw
Bleeding Gums
Bad Breath
Venereal Disease
Ulcer
Tuberculosis
Tonsillitis
Tobacco Habit
Thyroid Problem
Stroke
Swelling of Feet
Skin Rash
Shortness of Breath
Scarlet Fever
Rheumatic Fever
Respiratory Disease
Radiation Treatment
Psychiatric Care
Pacemaker
Nervous Problems
Mitral Valve Problems
Liver Disease
Kidney Disease
Jaw Pain
HIV Positive
High Blood Pressure
Hepatitis
Hemophilia
Heart Problems
Heart Murmur
Headaches
Glaucoma
Fainting
Epilepsy
Diabetes
Cough Up Blood
Persistent
Cough
Cortisone Treatment
Circulatory
Chemotherapy
Chemical Dependency
Cancer
Blood Disease
Back Problems
Asthma
Artificial Joints
Artificial Heart Valves
Rheumatism
Arthritis
Anemia
AIDS