All formsComplete, nothing to retype
Wade Kilby
Implant consult · Franklin, NC
Arrived completeSubmitted 3 hr ago · Ameritas · 3 of 3 pages
Worth a glance before the visit
On a bisphosphonateAnxiety 7 of 10, be gentle
Smile wishes: I would love to fix a dark front tooth before my daughter's wedding this fall.
Dental registration
Complete- Full name
- Wade Kilby
- Date of birth
- September 3, 1958 · age 67
- Sex
- Male
- Marital status
- Married
- Address
- 312 Wayah Rd, Franklin, NC 28734
- wkilby@example.com
- Cell phone
- 828-555-0139 · best time Mornings
- Home phone
- 828-555-0138
- Employer or school
- Retired · Retired contractor
- Spouse
- Brenda Kilby · Macon County Library
- Emergency contact
- Brenda Kilby (Spouse) · 828-555-0140
- How they found us
- Friend
- Social security
- Last four collected securely at the desk, no full SSN stored.
Medical history
Complete- Under a physician's care
- Yes · Cardiology, for blood pressure and bone density
- Recent hospitalization
- No
- Head or neck injury
- No
- Current medications
- Lisinopril; alendronate (for bone density)
- Special diet
- No
- Uses tobacco
- No
- In pain right now
- No
- General health
- Good
- Allergies
- None reported
- Conditions
- High blood pressureOsteoporosis
Dental history
Complete- Reason for visit
- Consult about replacing two lower molars with implants
- Former dentist
- Dr. Pruitt, Franklin
- Last visit
- About 2 years ago
- Last x-rays
- About 2 years ago
- Dental anxiety
- 7 of 10
- Past experience
- Fair
- Symptoms
- Missing teethSensitivity to hot
- Clench or grind
- No
- Jaw or TMJ soreness
- No
- Missing teeth
- Yes
- Teeth hurting now
- No
- Bisphosphonate medication
- Yes
- Smile wishes
- I would love to fix a dark front tooth before my daughter's wedding this fall.