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2290 Statesville Blvd., Salisbury, NC 28147

Mon - Thu 8AM - 5PM • Lunch 12:45 PM - 2PM

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- Meet Dr. Steve Yang
- Meet Our Team
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Patient Forms
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About Us
- Meet Dr. Steve Yang
- Meet Our Team
Dental Services
Patient Forms
Contact Us
Request Appointment

Patient Forms

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Yang Family Dentistry is always happy to accept new patients! For your convenience, you can complete your medical history information before you come to your dental appointment. This online form is HIPAA compliant and is secure as shopping online. You will notice a lock icon at the bottom of your web browser.

Medical History Form

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Patient Information
Patient Name
First Middle Last
Patient Address
Street Address Address Line 2 City State ZIP Code
Patient Home Phone
Patient Work Phone
Patient Cell Phone
Patient Email
Date of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Your info is secure- we use SSL!
Marital Status
Person to contact in case of emergency (ICE)
ICE Name
ICE Phone
How did you hear about our office?
If patient is a student, please list name of school or college
Spouse's name or parents name if patient is a minor

Responsible Party Information
(If different from above patient information)
Responsible Party Name
First Last
Name of person responsible for this account
Responsible Party Date of Birth
Date Format: MM slash DD slash YYYY
Responsible Party Address
Street Address Address Line 2 City State ZIP Code
Responsible Party Home Phone
Responsible Party Work Phone
Responsible Party Cell Phone
Responsible Party Email
Responsible Party Social Security Number
Your info is secure- we use SSL!
Relationship to Patient

Dental Insurance Information
Name of Insured
Date of Birth - Insured
Date Format: MM slash DD slash YYYY
Social Security Number - Insured
Your info is secure- we use SSL!
Relationship to Patient - Insured
Employer
Work Phone - Insured
Address of Insured (if different from responsible party)
Street Address Address Line 2 City State ZIP Code
Does the patient have additional dental insurance coverage?
- Yes
- No
- I don't know
Dental Insurance
IN ORDER TO PROPERLY FILE YOUR INSURANCE, WE MUST HAVE A COPY OF YOUR INSURANCE CARD AND THE ABOVE INFORMATION MUST BE COMPLETELY FILLED OUT. WE ARE NOT RESPONSIBLE FOR TRACKING DOWN YOUR INSURANCE INFORMATION.

Medical History
Are you under medical treatment right now?
- Yes
- No
- I don't know
Primary Care Physician
Any serious illness in the last 5 years?
- Yes
- No
If so, please list
Please list any medications you currently take
Please check the conditions that apply to you
- Acid Reflux
- High Blood Pressure
- Stroke
- Heart Attack/Heart Disease/Angina
- Heart Murmur/Mitral Valve Prolapse
- Pacemaker
- Artificial Heart Valve
- Family history of Heart Disease
- Rheumatic Fever
- Fainting/Seizures
- Asthma/Breathing Problems
- Tuberculosis
- Low Blood Pressure
- Cancer/Cancer Treatment
- Diabetes
- Family history of Diabetes
- Kidney Disease
- HIV/AIDS
- Artificial Joint
- Do you use tobacco in any form?
- Neurological Disorder
- Immune System Disorder
- Any blood disorder?
- Liver Disease/Jaundice and/or Hepatitis
- Have you ever been told by your doctor that you need an antibiotic before dental treatment?
- WOMEN, are you pregnant?
Any health issues not listed above?
Please list ANY allergies you have
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Comments
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Get In Touch!

2290 Statesville Blvd.
Salisbury, NC 28147

(704) 633-1322

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Now Accepting New Patients

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