If you are seeing us
for the first time, please complete the following form and bring it with
you on your initial visit. This expedites our paperwork and your visit.
THANK YOU!!
PATIENT INFORMATION
SPOUSAL (OR PARENTAL)
INFORMATION
Name:
Name:
Address:
(if P.O. Box, give street address too)
Address:
(if different than patient's)
City:
State:
Zip:
City:
State:
Zip:
Previous
Address:
(if current address is less than 1 year)
Previous
Address:
(if different than patient's)
City:
State:
Zip:
City:
State:
Zip:
Phone (H):
Phone (W):
Phone (H):
Phone (W):
Email:
Email:
SSN:
Date of Birth:
SSN:
Date of Birth:
Check One:
Married
Unmarried
Separated
Widowed
Sex:
Female
Male
Employer:
(Business name if self-employed)
Address:
City:
State:
Zip:
Whom may we thank for referring you?
Are you covered by dental insurance?
Yes
No
If your answer is YES, please complete the insurance
information below.
INSURANCE INFORMATION
Patients with insurance are
responsible for payment of their bills. We do not have contact with
insurance carriers. It is not always possible to predict which services
are covered by the carrier or how much the carrier will pay for a particular
service. The Dental Group will assist you in every way possible with
your insurance carrier.
Primary Insurance Co.
Secondary Insurance Co.
(if covered by more than one insurance)
Employee Name:
Employee SSN:
Employee Date of Birth:
Employee Sex:
Female
Male
Female
Male
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Zip:
Group Plan #:
Local Union #:
Policy # (or P.O.E. #):
Employer Name:
(Business name if self-employed)
(Business name if self-employed)
Employer Address:
City:
State:
Zip:
Zip:
Family Members Covered:
MEDICAL HISTORY
Physician:Date of last physical exam:
Are you currently being treated or
have been treated in the last year by a physician? Yes
No
If Yes, please explain:
Have you ever had any serious illness
or operation or been hospitalized within the last 5 years?
Yes
No
If Yes, please explain:
Has a physician informed you have
any of the following:
Heart Disease:
Yes
No
Artificial joint replacements (hip, knee,
etc.):
Yes
No
Heart Attack:
Yes
No
Allergies that cause Sinus Trouble, Asthma,
Hay Fever, Hives or Skin Rash:
Yes
No
Stroke:
Yes
No
Sinus Trouble:
Yes
No
Artificial Transplants or Implants
(pacemaker, heart valve):
Yes
No
Eye Disease:
Yes
No
Rheumatic Fever:
Yes
No
Ear Trouble:
Yes
No
Heart Murmur:
Yes
No
Kidney Disease:
Yes
No
Abnormal Blood Pressure:
Yes
No
Arthritis, Rheumatism:
Yes
No
Mitral Valve Prolapse:
Yes
No
Stomach Problems:
Yes
No
Diabetes:
Yes
No
Ulcers:
Yes
No
Blood Disorders:
Yes
No
Epilepsy, Seizures, Fainting Spells:
Yes
No
Bleeding Problems or Bruise Easily:
Yes
No
Mental Illness, Bi-Polar, Depression:
Yes
No
Liver Disease, Hepatitis or Other:
Yes
No
Venereal Disease:
Yes
No
Tumors or Cysts:
Yes
No
HIV Positive Test:
Yes
No
Cancer:
Yes
No
AIDS:
Yes
No
Radiation Treatment or Chemotherapy:
Yes
No
Lung Disease (TB, Emphysema):
Yes
No
WARNING: The following
may require Pre-Medication with Antibiotics: Heart Disease, Heart
Murmur, Pheumatic Fever, Mitral Valve Prolapse, Artificial Transplants
and Artificial Joint Replacements. PLEASE CHECK WITH YOUR PHYSICIAN.
Have you ever taken prescription medications
for weight control? Yes
No
Are you taking any drugs or
medications (circle below or list)?
Anticoagulant
High Blood Pressure Medication
Insulin or Oral Medication for Diabetes
Antihistamines and/or Aspirin
Oral Contraceptive or Birth Control Pills
Steroids
Nitroglycerine
Hormonal Therapy
Digoxin or Heart Medication
Other and for what condition?
Do you smoke or use tobacco regularly?
Yes
No
How much?
Are you sensitive, allergic
or have reacted adversely to any medications listed below?
Penicillin or other Antiobiotics:
Yes
No
Metals (copper, nickel, silver):
Yes
No
Codeine, Demerol or other Narcotics:
Yes
No
Barbiturates, Sedatives:
Yes
No
Aspirin:
Yes
No
Sulfa Drugs:
Yes
No
Dental Anesthetic, Injection or Gas:
Yes
No
Latex Allergy:
Yes
No
WOMEN: Are you pregnant?
Yes
No
Delivery Date?
Remarks about your health that we should
know about:
To the best of my knowledge, all of
the preceding answers are true and correct. If I ever have a change
in my health or if my medications change, I will inform the dentist
and/or hygenist at the next appointment.