Home
About Us
Services
Patients
Our Difference
Patient Education
Business Memberships
Contact

Follow Us

Get in Touch!

Phone: 915-800-1990

Fax: 915-800-1989

info@cimarrondentalstudio.com

6301 Northern Pass Dr Building 2,

El Paso, TX 79911

Dental Emergency?

Cimarron Dental Studio

REQUEST APPOINTMENT

habla español

Cimarron Dental Studio

REQUEST APPOINTMENT

The forms are available for pdf download here or you can fill them out online below.

DOWNLOAD PRINTABLE FILES

FILL FORM ONLINE

Flexible Payment Options

We accept all major payment methods for your convenience.

Patient Information Sheet

First name:

Last name:

MI:

Address:

City/State:

Zip code:

Cell Phone:

Home phone:

Work's Phone:

Date of Birth:

Social Security #:

Marital Status:

Married

Single

Widowed

Divorced

Gender:

E-mail:

Employment Status:

Employed

Self-employed

Retired

On active military duty

Other

Employer Name:

Position:

Free Text

Emergency Contact Information

Name:

Relationship to patient:

Cell phone:

Work phone:

Free Text

Insurance Information

Primary Insurance Carrier:

Insured's Name:

Relationship to Patient:

Insured's ID number:

Group number:

Free Text

Preferred Method of Contact

Preferred Method of Contact

Phone

Text

Email

Do we have permission to leave a detailed message?

Yes

No

Phone # to leave messages:

Free Text

Pharmacy Information

Pharmacy Name:

Address:

Pharmacy Phone #:

How did you hear about us?

Facebook

Instagram

Google

Other

Free Text

Authorization to Release Medical Information

Please check one:

Opt-In

I authorize Cimarron Dental Studio to release my dental information including the diagnosis, examination rendered to me, treatment to:

Authorized person for result:

Spouse

Child(ren)

Other

Opt-In

Information is not to be released to anyone.

Free Text

This release of information will remain in effect until terminated by me in writing.

Free Text

I verify that the above information is factual and true to the best of my knowledge. I understand that proof of insurance and/or copy, if applicable, is due at the time of service.

Date:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Medical History

Patient Name:

Age:

Nickname:

Most recent physical examination:

Name of Physician/and their specialty:

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Free Text

Do you HAVE or HAVE YOU ever had:

1. Hospitalization for illness or injury:

Yes

No

2. An allergic or bad reaction to any of the following:

aspirin, ibuprofen, acetaminophen, codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

chlorhexidine (CHX)

Iodine

metals (nickel, gold, silver)

latex

nuts

fruit

milk

red dye

other

no known drug allergies

other

3. Heart problems, or cardiac stent within the last six months:

Yes

No

4. History of infective endocarditis:

Yes

No

5. Artificial heart valve, repaired heart defect (PFO):

Yes

No

6. Pacemaker or implantable defibrillator:

Yes

No

7. Orthopedic or soft tissue implant (e.g joint replacement, breast implant):

Yes

No

8. Heart murmur, rheumatic or scarlet fever:

Yes

No

9. High or low blood pressure:

Yes

No

10. A stroke (taking blood thinners):

Yes

No

11. Anemia or other blood disorder:

Yes

No

12. Prolonged bleeding due to a slight cut (or INR > 3.5):

Yes

No

13. Pneumonia, emphysema, shortness of breath, sarcoidosis:

Yes

No

14. Chronic ear infections, tuberculosis, measles, chicken pox:

Y

No

15. Breathing problems (e.g asthma, stuffy nose, sinus congestion):

Yes

No

16. Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting):

Yes

No

17. Kidney Disease:

Yes

No

18. Liver disease or jaundice:

Yes

No

19. Vertigo (e.g "the room is spinning"):

Yes

N

20. Thyroid, parathyroid disease, or calcium deficiency:

Yes

No

21. Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome):

Yes

No

22. High Cholesterol or taking statin drugs:

Yes

No

23. Diabetis (HbA1c)

Yes

No

23. Diabetis (HbA1c)

24. Stomach or duodenal ulcer:

Yes

No

25. Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia):

Yes

No

26. Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates):

Yes

No

27. Arthritis or gout:

Yes

No

28. Autoimmune disease (e.g. rheumatoid, lupus, scleroderma):

Yes

No

29. Glaucoma:

Yes

No

30. Contact lenses:

Yes

No

31.Head or neck injuries:

Yes

No

32. Epilepsy, convulsions (seizures):

Yes

No

33. Neurologic disorders (e.g. Alzheimer's disease, dementia, prion disease):

Yes

No

34. Viral Infections and cold sores:

Yes

No

35. Any lumps or swelling in the mouth:

Yes

No

36. Hives, skin rash, hay fever:

Yes

N

37. STI/STD/HPV:

Yes

No

38. Hepatitis:

Yes

No

38. Hepatitis (type)

39. HIV/AIDS:

Yes

No

40. Tumor, abnormal growth:

Yes

N

41. Radiation therapy:

Yes

No

42. Chemotherapy, immunosuppresive medication:

Yes

No

43. Emotional difficulties:

Yes

No

44. Psychiatric treatment or antidepressant medication:

Yes

No

45. Concentration problems or ADD/ADHD:

Yes

No

46. Alcohol/recreational drug:

Yes

No

Free Text

Are you

47. Presently being treated for any other illness:

Yes

No

48. Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea):

Yes

No

49. Taking medication for weight management:

Yes

No

50. Taking dietary supplements, vitamins, and/or probiotics:

Yes

No

51. Often exhausted or fatigued:

Yes

No

52. Experiencing frequent headaches or chronic pain:

Yes

No

53. A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis):

Yes

No

54. Considered a touchy/sensitive person:

Yes

No

55. Often unhappy or depressed:

Yes

No

56. Taking birth control pills:

Yes

No

57. Currently pregnant:

Yes

No

58. Diagnose with a prostate disorder:

Yes

No

Describe any current medical treatment, impeding surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injection):

Free Text

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

Year 1 - Drugs:

Year 1 - Purpose:

Year 2 - Drugs:

Year 2 - Purpose:

Free Text

Please advise us in the future of any change in your medical history or any medications you may be taking.

Date:

ASA:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Dental History

Patient Name:

Age:

Nickname:

Referred by:

Previous Dentist:

Date of most recent dental exam:

Date if most recent treatment (other than a cleaning):

How long have you been a patient? (Months/Years):

Date of most recent x-rays:

How would you rate the condition of your mouth?

Excellent

Goo

Fair

Poor

I routinely see my dentist every:

3 mo.

4 mo.

6 mo.

12 mo.

Not routinely

Free Text

What is your immediate concern?

What is your immediate concern?

Free Text

Please answer Yes or No to the following:

Free Text

Personal History

1. Are you fearful of dental treatment?

Yes

No

2. Have you had an unfavorable dental experience?

Yes

No

3. Have you ever had complications from the past dental treatments?

Yes

No

4. Have you ever had trouble getting numb or had reactions to local anesthetics?

Yes

No

5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

Yes

No

5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

Yes

No

Free Text

Gum and Bone

7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?

Yes

No

8. Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?

Yes

No

9. Have you ever noticed an unpleasant taste or odor in your mouth?

Yes

No

10. Is there anyone with a history of periodontal disease in your family?

Yes

No

11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?

Yes

No

12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes

No

13. Have ever experience a burning or painful sensation in your mouth not related to your teeth?

Yes

No

Free Text

Tooth Structure

14. Have you had any cavities within the past 3 years?

Yes

No

15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes

No

16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Yes

No

17. Are any teeth sensitive to hot, cold, sweets, or do you avoid brushing any part of your mouth?

Yes

No

18. Do you have grooves or notches on your teeth near the gum line?

Yes

No

19. Have you ever had a broken teeth, chipped teeth, or had a toothache or cracked filling?

Yes

No

20. Do you frequently get food caught between any teeth?

Yes

No

Free Text

Bite and Jaw Joint

21. Do you have problems with your jaw point? (pain, sound, limited opening, locking. popping):

Yes

No

22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

Yes

No

23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, other hard, dry foods?

Yes

No

24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?)

Yes

No

25. Are your teeth becoming more crooked, crowded or overlapped?

Yes

No

26. Are your teeth developing spaces or becoming more loose?

Yes

No

27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

Yes

No

28. Do you place your tongue between your teeth or close your teeth against your tongue?

Yes

No

29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Yes

No

30. Do you clench or grind your teeth together in the daytime or make them sore?

Yes

No

31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

Yes

No

32. Do you wear or have you ever worn a bite appliance?

Yes

No

Free Text

Smile Characteristics

33. Is there anything about the appearance of your mouth? (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?

Yes

No

34. Have you ever bleached (whitened) your teeth?

Yes

No

35. Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes

No

36. Have you been disappointed with the appearance of previous dental work?

Yes

No

Date:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Primary Dental Insurance

Policy Holder's Name:

No Insurance:

DOB:

ID #/Social Security #:

Group #:

Employer:

Dental:

Insurance Plan Name & Address:

Free Text

Hobby Form

1. Patient hobbies/interests:

2. Does the patient have any children and/or pets?

3. What is your occupation or school major?

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Cimarron Dental Studio

REQUEST APPOINTMENT

Get in Touch

Phone: 915-800-1990

Fax: 915-800-1989

Business Hours

Monday: Closed

Tuesday: 9 AM–6 PM

Wednesday: 9 AM–6 PM

Thursday: 9 AM–6 PM

Friday: 9 AM-6 PM

Saturday: By Appointment Only

Sunday: Closed

6301 Northern Pass Dr Building 2,

El Paso, TX 79911

Navigation links

Home
About Us
Services
Patients
Our Difference
Patient Education
Business Memberships
Contact

Follow Us

© 2025 All Rights Reserved | Cimarron Dental Studio

Share by: