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    Hershey Dentist – Bhargav Patel, DMD - Family, Cosmetic and Implant Dentistry

    The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.

    Please do not use this form to cancel or change an existing appointment.

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    575 E.Chocolate Ave HERSHEY, PA 17033

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    Medical History

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
    Are you under a physician`s care now?
    Have you ever been hospitalized or had a major operation?
    Have you ever had serious, pills, or drugs?
    Are you talking any medications, pills, or drugs?
    Do you take, or have you taken, Phen-fen or redux?
    Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
    Are you on a special diet?
    Do you use tobacco?
    Women: Are you..
    Are you allergic to any of the following?
    Other
    Do you use controlled substances?
    Do you have, or have you had, any of the following?
    • AIDS / HIV Positive
    • Alzheimer`s Disease
    • Anaphylaxis
    • Anemia
    • Angina
    • AnginaArthritis / Gout
    • Artificial Heart valve
    • Artificial Joint
    • Asthma
    • Blood Disease
    • Blood Transfusion
    • Breathing Problem
    • Bruise Easily
    • Cancer
    • Chemotherapy
    • Chest pains
    • Cold sores/Fever Blisters
    • Congenital heart disorder
    • Convulsions
    • Cortisone medicine
    • Diabetes
    • Drug Addiction
    • Easily Winded
    • Emphysema
    • Epilepsy or Seizures
    • Excessive Bleeding
    • Excessive Thirst
    • Fainting Spells/Dizziness
    • Frequent cough
    • Frequent Diarrhea
    • Frequent Headaches
    • Genital Herpes
    • Glaucoma
    • Hay Fever
    • Heart Attack/Failure
    • Heart Murmur
    • Heart pace maker
    • Heart Trouble/Disease
    • Hemophilia
    • Hepatitis A
    • Hepatitis B or C
    • Herpes
    • High Blood Pressure
    • High Cholesterol
    • Hives or rash
    • Hypoglycemia
    • Irregular Heartbeat
    • Kidney problems
    • Leukemia
    • Liver Disease
    • Low Blood Pressure
    • Lung Disease
    • Mitral valve prolapsed
    • Osteoporosis
    • Pain in jaw joints
    • Parathyroid disease
    • Psychiatric Care
    • Radiation treatments
    • Recent Weight Loss
    • Renal Dialysis
    • Rheumatic fever
    • Rheumatism
    • Scarlet Fever
    • Shingles
    • Sickle Cell Disease
    • Sinus Trouble
    • Spina Bifida
    • Stomach/Intestinal Disease
    • Stoke
    • Swelling of Limbs
    • Thyroid disease
    • Tonsillitis
    • Tuberculosis
    • Tumors or Growths
    • Ulcers
    • Venereal Disease
    • Yellow Jaundice
    Have you ever had any serious illness not listed above?