YAJAIRA MARTINEZ DDS
SANTIAGO URIBE DDS
NATALIA LUQUE DDS

3532 20th Street
San Francisco CA 94110
415-643-6424

PATIENT INFORMATION

LAST
FIRST
MI
PREFERRED TITLE
PARENT/GUARDIAN NAME(S)
SCHOOL/LOCATION
ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person Not at the patient’s address:

NAME
RELATIONSHIP

EMPLOYMENT INFORMATION

ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE

INSURANCE INFORMATION

LAST
FIRST
MI
CITY
ST
ZIP CODE
CITY
ST
ZIP CODE

DENTAL HISTORY

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Valencia Dental Center 3532 20th Street San Francisco CA 94110 (p) 415-643-6424 (f) 415-643-4359 valencia.dentalctr@gmail.com