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(918) 906-2525

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Home
Our Services
- All-on-4 Dental Implants
- Zygomatic and Pterygoid
New Patient Form
Reviews
FAQs
Contact Us
Terms of Use
Privacy Policy

Contact Us

(918) 906-2525

deanna@chriswarddds.com

5522 South Lewis Avenue, Tulsa,
Oklahoma 74105, United States

New Patient Form

Filling out this form allows us to prepare for your visit and deliver the best possible care.

Contact Information

Patient Information

Patient Information

Address

City

State

Zip

Primary Phone

Email

Preferred Pharmacy

Preferred Pharmacy

Pharmacy Name

Pharmacy Address

Pharmacy Phone Number

Quick Reference Section

Quick Reference Section

Have you been under the care of a medical doctor during the past two years?

Do you have Diabetes? If yes, please provide current A1C and date of last A1C test:

Are you taking or have you ever taken any of the following medications? Fosamax, Actonel, Boniva, Prolia, Aredia, Reclast, Zometa, Xgeva?

Please list other current medications you are taking. Include name of medicine, reason, dosage, how many times/day, last time taken (prior to surgery).

Are you taking any weight loss medication? Semaglutide, Mounjaro, Ozempic, Rybelsus, Wegovy, Phentermine?

Do you currently use, or have you ever used, any illegal or non-prescribed substances?

Do you have, or have you ever had, any of the following?

Heart Failure

Heart Disease

Heart Attack, If Yes, what year?

Heart Problems

Glaucoma Codeine

Tobacco Products

Drug Addiction

Kidney Trouble

Do you have Osteoporosis?

Do you smoke tobacco?

Do you use any marijuana or cannabis products?

Not Applicable

Are you taking any of the following medications?

Anticoagulants/Blood

Aspirin

Ibuprofen/Tylenol

Steroids

Codeine or other narcotics

Iodine

Tranquilizers

Other medication(s)

Not Applicable

Medical Background

Medical Background

Date of Birth

Age

Gender

Height

Weight

Are you in good general health?

Have there been any changes to your general health in the past year?

Have you had any serious illness or operation within the last 5 years?

Have you ever had any excessive bleeding requiring special treatment?

Women’s Health

Women’s Health

Are you pregnant, trying to get pregnant, or breastfeeding?

Are you currently undergoing any hormonal therapies?

Do you have any problems with your menstrual period?

Allergies

Allergies

Are you taking oral contraceptives?

Have you ever had a blood transfusion?

Do you have an autoimmune disease?

Are you regularly exposed to X-rays or any other ionizing radiation or substances?

Are you currently wearing contact lenses, including daily or extended-wear lenses?

Are you allergic to, or have you had an allergic reaction or adverse reaction to, any of the following?

Local anesthetic

Penicillin

Codeine

Latex

Acrylic

Metals

Sulfa Drugs

Iodine

Sleeping Pills

Barbiturates

Aspirin

Sedatives

Antibiotics

Other

Not Applicable

Medical History

Medical History

Do your ankles swell?

What is your normal blood pressure?

Do you use extra pillows to sleep?

Have you ever vomited blood?

Do you have any blood pressure issues?

Do you have any diarrhea?

Are you a hemophiliac?

Do you drink alcohol?

Have you been to the dentist before?

Have you ever undergone chemotherapy or radiation therapy?

Do you have hypothyroidism or hyperthyroidism?

Does anyone in your family have diabetes?

Is there any family history of blood disorders?

Are you now, or have you ever been treated for a psychological disorder?

Have you ever had any abnormal bleeding after any surgery, extraction or trauma?

Do you currently have, or have you had, any of the following?

Chest Pain

Heart Failure

Heart Disease

Heart Problems

Depression

Congenital Heart Disease

Liver Disease

Hypertension

Heart Murmur

Rheumatic Fever

Anxiety

Sickle Cell Disease

Sinus Trouble

Artificial Joints

Thyroid Disease

Anemia

Blood Transfusions

Mitral Valve

Prolapse (MVP)

Inflammatory Rheumatism

Shortness of Breath

Ulcers

Mental Health Issues

Emphysema

Fainting/Dizziness

Eating Disorder

Epilepsy/Seizures

Persistent Cough

Tuberculosis

Asthma

Hepatitis A

Hepatitis B

Hepatitis C or D

Pacemaker

Night Sweats

Stroke

Drug Addiction

Cold Sores

Radiation Therapy

Osteoporosis

Hives/Skin Rashes

Alcoholism

Dental Implant

Dentures/Partials

Birth Defects

HIV, AIDS, ARC

Hay Fever

Tobacco Use

Acid Reflux

Jaundice

Kidney Trouble

Diabetes

Chemotherapy

Cancer

Transplant

Bone Infections

Chest pain after exertion

Shortness of breath after mild exercise

Not Applicable

Dental History

Dental History

Previous Dentist's Name

Previous Dentist's Address

Last Dental Visit

Approx. Date of Last X-rays

Are you having tooth or gum pain at this time?

Have you ever had a bad experience in a dental office?

Are you satisfied with the appearance of your teeth?

Do you feel nervous about dental treatment?

Do you have headaches, earaches or neck pain?

Are there any other conditions or health concerns you would like to address?

Is there anything you would like to speak with the Doctor about in private?

Do you frequently experience sinus problems

What is your chief complaint? What brings you in today?

Facial/Jaw Pain

Facial/Jaw Pain

Regarding facial or jaw pain, do you:

Have frequent headaches

Avoid certain foods

Experience popping/clicking

Have pain in temples

Have times when your jaw locks open/closed

Have pain in jaw

Currently have a jaw injury

Currently have pain around ear

Currently have a head injury

Not Applicable

Have you had teeth straightening? Please explain:

Orthodontic History

Orthodontic History

Do you have, or have you ever had, any of the following?

Night Guard

Oral Surgery

Periodontal

Treatment

Your bite adjusted

Smile makeover

Cosmetics

Retainer

Not Applicable

Have you ever had orthodontic treatment?

Other Dental Conditions

Other Dental Conditions

Do you have, or have you ever had, any of the following?

A history of smoking/dipping

A history of biting cheeks or lip

Tooth-colored fillings

Burning tongue

Wisdom teeth

Tooth replacement

Fracture tooth syndrome

Dental phobias

A habit of nail-biting

Not Applicable

Do you hold foreign objects (pencils, pipe, pins, nails, fingernails, etc.) with your teeth?

Sleep/Airway Issues

Sleep/Airway Issues

Has the patient seen an ear, nose or throat specialist?

Is the patient using a sleep apnea device?

Prior TMJ treatment

CPAP

Not Applicable

Do you have any sleep/airway issues?

Does the patient tend to be a mouth breather?

Does the patient snore at night?

Does the patient seem rested in the morning?

Is the patient often sleepy during the day?

Not Applicable

Free Text

Consent

Opt-In

By checking this box, I hereby authorize and request the performance of dental implant services for myself.

Thank you so much for contacting our dental implant practice. While we strive to respond to all inquiries right away, we may be away from the desk helping a patient or out of the office. We will do our best to reach out to you shortly.

Please note, if this is a dental emergency, it would be best to call our dental implant practice as this is the fastest way to reach us (918) 906-2525.

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Contact Us

(918) 906-2525

deanna@chriswarddds.com

5522 South Lewis Avenue, Tulsa, Oklahoma 74105, United States

Helpful Links

Our Services
All-on-4 Dental Implants
Zygomatic and Pterygoid
Reviews
FAQs
Terms of Use
Privacy Policy

Our Services
All-on-4 Dental Implants
Zygomatic and Pterygoid
Reviews
FAQs
Terms of Use
Privacy Policy

Business Hours

Monday: 8:00 am - 4:00 pm
Tuesday: 8:00 am - 4:00 pm
Wednesday: 8:00 am - 4:00 pm
Thursday: 8:00 am - 4:00 pm
Friday: Closed
Saturday: Closed
Sunday: Closed

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