Download pdf Version 1) Health History
2) Dental History
3) (optional) Cosmetic Dentistry Questionnaire

Consolidated Patient Form

1- HEALTH HISTORY
2- DENTAL HISTORY
EMERGENCY CONTACT DETAİLS
Please give the name and telephone number of the closest relative or friend (not living with you) to contact in case of emergency
3- COSMETİC DENTAL HISTORY(Optional)
Hold a mirror 12-14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, then answer the following questions. If you are not happy with the appearance of your teeth, ask Dr. Levey how cosmetic dentistry can improve your smile.
DECLARATION
To the best of my knowledge, all answers are correct. I will notify Dr.Levey if any changes in my health or medication should occur. I consent to necessary treatment being performed on me by Dr. Levey and his staff, and also to the use of photos for educational and commercial purposes. Also, I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma; cardiac stimulation; temporary or rarely, permanent numbness; or muscle soreness. I understand that occasionally needles may break and require surgical retrieval.