Patient Information

LAST PREFERRED NAME
FIRST MIDDLE
ADDRESS
CITY STATE ZIP
HOME PHONE () WORK PHONE ()
EMAIL CELL PHONE ()
SEX   M F MARITAL STATUS   S M D W
BIRTH  DATE EMPLOYED BY
EMPLOYERS ADD CITY
FULL TIME STUDENT?  Y  N IF YES, SCHOOL
CITY ZIP
REFERRED BY

Dental History

PREVIOUS DENTIST
ADDRESS PHONE ()
HOW LONG SINCE YOUR LAST DENTAL VISIT?
WHAT WAS DONE THEN?
HOW LONG SINCE: YOUR TEETH WERE LAST CLEANED?
LAST FULL SET OF X-RAYS?
HOW OFTEN DO YOU: HAVE YOUR TEETH CLEANED?
BRUSH YOUR TEETH?

HAVE ANY OF THE FOLLOWING CONDITIONS EVER BEEN PERTINENT TO YOUR MEDICAL OR DENTAL HISTORY.

BLEEDING GUMS Y N PAIN OR RINGING IN EARS Y N BURNING TONGUE Y N
TENDER OR SWOLLEN GUMS Y N TIRED JAWS Y N SINUS CONDITION Y N
LOOSE TEETH Y N DO YOU CLINCH YOUR TEETH Y N HAVE YOU HAD:  
SENSITIVE TEETH Y N COMPLICATED EXTRACTION Y N    Orthodontics (braces) Y N
MISSING TEETH NOT REPLACED Y N UNUSUAL DENTAL EXPERIENCES Y N    Periodontal (gum) Tx Y N
PAINFUL OR SORE AREAS Y N THUMB OR FINGER SUCKING Y N    Crown (cap) or Bridges Y N
           Root Canal (Endodontics) Y N
CHIEF COMPLAINT
ARE YOU HAPPY WITH YOUR SMILE?
CAN YOU CHEW ON BOTH SIDES?
ARE THERE ANY FOODS YOU CAN'T EAT
IF YOU COULD CHANGE ANYTHING ABOUT YOUR DENTAL HEALTH WHAT WOULD IT BE


REMARKS


Medical History

Have any of the following conditions ever been pertinent to your medical history.
Cancer Y N High Blood Pressure Y N Tuberculosis Y N Bladder Trouble Y N
Radiation Therapy Y N Low Blood Pressure Y N Multiple Sclerosis Y N Epilepsy Y N
Heart Trouble Y N Blood Transfusions Y N Thyroid Condition Y N Hepatitis Y N
Rheumatic Fever Y N Ulcer Y N Hay Fever Y N HIV Y N
Heart Murmur Y N Emphysema Y N Asthma Y N AIDS Y N
Artificial Valve Y N Diabetes Y N Kidney Trouble Y N Venereal Disease Y N
Artificial Joints Y N Anemia Y N Latex Allergy Y N Fen-Phen Y N

ARE YOU PREGNANT?Y N
HAVE YOU EVER BEEN TOLD NOT TO TAKE NOVOCAINE?Y N
DO YOU HAVE A COLD?Y N
ARE YOU PRESENTLY UNDER THE CARE OF A PSYCHIATRIST?Y N
ARE YOU PRESENTLY OR HAVE YOU EVER TAKEN STEROIDS?Y N
EVER HAD ABNORMAL BLEEDING FROM EXTRACTION OF TEETH OR CUTS?Y N
ARE YOU ALLERGIC TO ANY PARTICULAR MEDICINE OR DRUGS?Y N
IF SO, WHICH MEDICINES OR DRUGS?
LIST ALL DRUGS OR MEDICATIONS YOU ARE PRESENTLY TAKING OR HAVE TAKEN IN THE PAST 12 MONTHS

IN CASE OF EMERGENCY NOTIFY PHONE () RELATION
PHYSICIAN PHONE () LAST EXAM

Responsible Party

LAST TITLE
FIRST MIDDLE
ADDRESS
CITY STATE ZIP
HOME PHONE () BIRTH DATE
WORK PHONE () SEX M F
NUMBER OF CHILDREN
Preferred method of payment CASH CHECK CREDIT CARD
Nearest friend or relative NOT living in same household:
Name Phone ()

Insurance

PRIMARY DENTAL INSURANCE:
EMPLOYER'S NAME PHONE ()
ADDRESS CITY St. ZIP
EMPLOYEE'S NAME RELATION TO PATIENT
DOB
INSURANCE COMPANY NAME
ADDRESS CITY St. ZIP
PHONE# ()

CONSENT

I have answered all questions honestly and to the best of my knowledge. If further ifnormation is needed, you have my permission to ask the respective heatlh care prvider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication. I authorize the doctor or his staff to take any necessary x-rays, models, photos, and other diagnostic aides needed to make a thorough diagnosis of the patients dental needs. I authorize the doctor and staff to perform and administer treatment, medication, and therapy that may be indicated.

AGREEMENT TO PAY

Payment for dental services provided in this office for myself and my dependents are due and payable at the time services are rendered unless financial arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a billing charge may be added to my account. If an account must be turned over to a collection agency the fee charged by that agency will be added to my account.

Please type your name below, indicating the above information is correct. Typing your name indicates your approval and acts as a signature.
Signature Date