Contact - Silvaggio Prosthodontics

Call Today: 717-393-0550 or complete the contact form below to send us an email.

Please complete the Medical History Form and the Information Disclosure Form located at the bottom of this page and submit it prior to your first appointment.

Contact Form
Name*
First Last
Email

Phone*
Question/Comment:*
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Medical History Form
Name*
First Last
Date of Birth*
Are you under a physician's care now?*
Yes
No
If yes, please explain:*
Have you ever been hospitalized or had a major operation?*
Yes
No
If yes, please explain:*
Have you ever had a serious head or neck injury?*
Yes
No
If yes, please explain:*
Are you taking any medications, pills, or drugs?*
Yes
No
If yes, please explain:*
Do you take, or have you taken, Phen-Fen or Redux?*
Yes
No
Details:
Are you on a special diet?*
Yes
No
Details:
Do you use tobacco?*
Yes
No
Do you use controlled substances?*
Yes
No
Women:
Pregnant / Trying to get pregnant?*
Yes
No
Taking oral contraceptives?*
Yes
No
Nursing?*
Yes
No
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other
If yes, please explain:*
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint Asthma
Blood Disease
Blood Transfusion
Breathing Problems
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
Hepititis A
Hepititis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
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
Stroke
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?*
Yes
No
If yes, please explain:*
Comments:
Consent*

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Today's Date*
Date Format: MM slash DD slash YYYY
Information Disclosure Form
I give permission for Dr. Christian Silvaggio to disclose and discuss my medical information with:
Spouse
Son(s)
Daughter(s)
Father
Mother
Guardian or Caretaker
Other
This authorization will remain in effect until notified by patient in writing of disclosure changes.
Patient Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY

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Women:

Information Disclosure Form

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