Form

Previous Treatment Information

Please call your previous dental office and request the dates of
the following treatment. We want to ensure the
dentist can do a thorough exam.

Today's Date

Patient name

Date of last exam

Date of last prophylaxis (teeth cleaning)

Date of last Bitewing x-rays:

Date of last full mouth x-rays:

Date of last panoramic x-ray:

Date of last fluoride (for children):

Add current x-rays here

Upload or drag files here

Or email to: receptionist@elkriverfamilydentistry.com Or fax to: 763-269-8692

Signature

303 Main St. · Elk River, MN 55330 · (763) 441-9181 · fax (763) 269-8692 · www.elkriverfamilydentistry.com