Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please contact us and we will be happy to help.
After explanation by the doctor, l hereby authorize the performance of dental services upon the above named patients and whatever procedures that the judgment of the doctor may decide in order to carry out these procedures. I also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and advisable by the doctor.
Any other medications, vitamins or supplements, if so, please list:
Being overweight is now recognized as a strong risk factor for gum disease. Obesity and gum disease are both risk factors for heart disease and diabetes. Thus, if you are over your ideal weight it is vitally important for you to eliminate any gum inflammation to lower your risks for more serious health problems.
Tobacco users are more likely to develop gum disease. Gum disease itself has recently been linked with an increased risk for heart disease. Since tobacco users are already at an increased risk for heart disease (and since gum disease only worsens that risk) it is vitally important for tobacco users to do whatever is necessary to eliminate gum disease.
Do you have any of the following risk factors for heart disease? Check all that apply
Gum disease is now a recognized risk factor for heart disease. If your gums are inflamed, bacteria from your mouth can get into your blood stream and lodge into your heart vessels. Finding out if you have gum disease and then keeping it at bay over your lifespan can lower your risk for heart disease and stroke.
Low vitamin D levels have been linked with a higher risk for gum disease and many other diseases. Many people are chronically low in Vitamin D it is important to find out your vitamin D level and optimize it if your level is low.
Lack of quality sleep and sleep apnea are very serious. Sleep apnea is linked to gum disease and many other diseases. Part of overall wellness is keeping any gum inflammation in your mouth to a minimum. This is especially important if you have any sleep abnormalities
Modern Family Dental Care Taj M. Haynes DMD, PA 8455 Pit Stop Ct NW, Ste 140 Concord, NC 28027