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Kevin Patel, DMD

Sheena Neil, DMD

To Schedule An Appointment

Call 910.944.5600

908 N. Sandhills Blvd

Aberdeen, NC 28315

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TMJ History

Medical Insurance

Subscriber Name

Subscriber Date of Birth

Subscriber ID/SSN

Group Number (if applicable)

Claims Mailing Address

Medical History - have you been diagnosed or are taking medication for any condition?

Medication - Please list any medications prescribed by your physician.

Please list any symptoms you are experiencing

Jaw Pain

Facial Pain

Joint Sounds - clicking/popping

Lock Jaw

Changes in Bite

Grinding

Headaches/Migraines

Clenching

Broken Teeth

Please let us know if you are having any other symptoms not listed above

Have you ever been treated for TMJ disorder before?

Yes

No

If yes, please explain types of treatment

Did any jaw or facial pain result from trauma or an accident?

Yes

No

If yes, please elaborate

Thanks for submitting!

Office Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

8 AM - 4 PM

Closed

Closed

Closed

To Schedule An Appointment

Call 910.944.5600

Phone:

Fax:

Email:

910-944-9334

info@dogwooddental.net

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