All formsComplete, nothing to retype
Miguel Alvarado
Implant consult · Franklin, NC
Arrived completeSubmitted just now · Cigna Dental · 3 of 3 pages
Dental registration
Complete- Full name
- Miguel Alvarado
- Date of birth
- June 20, 1979 · age 47
- Sex
- Male
- Marital status
- Married
- Address
- 56 Depot St, Franklin, NC 28734
- malvarado@example.com
- Cell phone
- 828-555-0171 · best time Afternoons
- Employer or school
- Alvarado Masonry · Mason and owner
- Spouse
- Rosa Alvarado · Angel Medical Center
- Emergency contact
- Rosa Alvarado (Spouse) · 828-555-0172
- How they found us
- Family
- Social security
- Last four collected securely at the desk, no full SSN stored.
Medical history
Complete- Under a physician's care
- No
- Recent hospitalization
- No
- Head or neck injury
- No
- Current medications
- None
- Special diet
- No
- Uses tobacco
- No
- In pain right now
- No
- General health
- Excellent
- Allergies
- None reported
- Conditions
- None reported
Dental history
Complete- Reason for visit
- Consult about an implant for a lost molar
- Former dentist
- Dr. Pruitt, Franklin
- Last visit
- About 8 months ago
- Last x-rays
- About 8 months ago
- Dental anxiety
- 2 of 10
- Past experience
- Good
- Symptoms
- Missing teeth
- Clench or grind
- No
- Jaw or TMJ soreness
- No
- Missing teeth
- Yes
- Teeth hurting now
- No
- Bisphosphonate medication
- No