All formsComplete, nothing to retype
Priya Nandan
New patient exam · Clayton, GA
Arrived completeSubmitted 18 hr ago · Guardian · 3 of 3 pages
Worth a glance before the visit
Penicillin allergy
Dental registration
Complete- Full name
- Priya Nandan
- Date of birth
- April 12, 1990 · age 36
- Sex
- Female
- Marital status
- Married
- Address
- 148 Warwoman Rd, Clayton, GA 30525
- pnandan@example.com
- Cell phone
- 706-555-0192 · best time Evenings
- Employer or school
- Rabun County Schools · Teacher
- Spouse
- Anil Nandan · Self-employed
- Emergency contact
- Anil Nandan (Spouse) · 706-555-0193
- How they found us
- Internet
- 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
- Good
- Women's health
- Pregnant: No · Contraceptives: No · Nursing: No
- Allergies
- Penicillin
- Conditions
- None reported
Dental history
Complete- Reason for visit
- New patient cleaning and exam for the whole family
- Former dentist
- Dr. Sanders, Athens
- Last visit
- About 14 months ago
- Last x-rays
- About 14 months ago
- Dental anxiety
- 3 of 10
- Past experience
- Good
- Symptoms
- Sensitivity to cold
- Clench or grind
- No
- Jaw or TMJ soreness
- No
- Missing teeth
- No
- Teeth hurting now
- No
- Bisphosphonate medication
- No