• Welcome to our practice. We look forward to providing you with excellent care in dentistry and facial aesthetics. Please fill out the following information so we may best serve you.

    Dr. Carolina Borgenicht • Dr. Santiago Lopez

Patient Information

  • Today's Date
  • First Name
  • Last Name
  • Home Address
  • City
  • State
  • Country
  • Age
  • Date of Birth (mm/dd/yy)
  • Email Address
  • Sex
  • Male Female
  • Marital Status
  • Single Married Widowed Separated Divorced
  • Home PH #
  • Cell PH #
  • Work PH #
  • Employer
  • Occupation
  • How Did You Hear About Us?
  • Referral:
  • Who may we thank for recommending us?
  •  
  • Online:
  • Google Facebook
  • other online source
  •  
  • Event:
  • Seminar Bridal Show Spa Event School Event
  •  
  • Mailing:
  • Magazine Postcard

Emergency Contact

  • Name of person we should contact in case of emergency
  • Relationship
  • Home PH #
  • Cell PH #

Please Tell Us About Yourself

  • Reason for today's visit
  • Have you had Botox® treatment in the past?
  • Have you had facial fillers (such as Juvederm®, Restylane, Perlane, Voluma) in the past?
  • Yes No
  • If yes, how long ago?
  • Do you clench your teeth?
  • Yes No
  • Do you have TMJ pain?
  • Yes No
  • Do you get frequent headaches?
  • Yes No
  • Date of last dental cleaning
  • Date of last dental x-rays
  • I, the undersigned (patient or legally responsible party), authorize treatment to be rendered by the doctor and his/her staff, and I assume all financial responsibility for treatment given, services rendered and all associated costs incurred as a result of my treatment. I acknowledge that all the information contained herein is true and correct and give my permission to verify any of the information provided. I, the undersigned (patient or legally responsible party), have reviewed the HIPPAA Privacy Policy Notice available in the office of Elite Dental & Aesthetics.
  • Signature of Patient (or Parent/Guardian)
  • Date
FAC-NP
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