• Medical + Dental History

    For new + existing patients!
  • PATIENT INFORMATION

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  • FOR ADULT PATIENTS

  • PARENT #1 Information (MINORS)

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  • PARENT #2 Information (MINORS)

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  • MEDICAL + DENTAL HISTORY

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  • Our 12 second scan is less than a traditional film based panoramic radiograph when used with a lead apron and neck collar. CBCT offers our patients enhanced diagnostic value at a significantly reduced exposure. Simultaneously, CBCT scans can image the head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws, and surround supporting bone using CBCTs for those limited purposes. Our training and dental license does not provide for evaluating and diagnosing outside those areas. However, since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull, or arteries. We can have your CBCT scan read by an oral radiologist for a fee of $120.00. If you are interested in taking advantage of this service, please complete the applicable section below.

  • I authorize Dr. Cooke and/or her staff to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care. I authorize release of any information concerning my (or my child’s) health care for the purpose of evaluation and administering claims for insurance benefits. I authorize release of any information concerning my (or my child’s) health care for advice and treatment to interdisciplinary team members. I understand that where appropriate, credit bureau reports may be obtained. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment, and to the use of the same by the doctor. The information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.

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