Date:
E-mail Address:
Lastname: Firstname: MI:
Title:
Gender:
Address:
City: State:
Zip:
Marital Status:
Hm #:
Pager / Other #: Cell #:
Wk #: Ext #: DL #:
Employer:
Employer's Address:
Occupation:
How did you find us?
Other family member seen by us:
Previous / Present Dentist:
Last Visit Date:
SPOUSE
His / Her Name:
Employer:
Wk #: Ext.: SS #:
Birthdate: DL #:
Person Responsible for Account:
Wk #: Ext.: Hm #:
Billing Address:
Relation: SS #:
Employer: DL #:
DENTAL HISTORY
Why are you going to the dentist?
Do you require antibiotics defore dental treatment?
Are you currently in pain?
Have you ever had a serious / difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
Your current dental health is:
Do you like your smile?
Do your gums ever bleed?
How many times a week do you floss?
How many times a day do you brush?
Type of bristles?
Have you ever taken Phen_Fen?
(Also known as Redux or Pondimin)
If so, when?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to infom this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature: Name: Last Name:
*
* Please enter your Complete Name as your signature.
Payment is due in full at the time of treatment unless prior arrangement have been approved.
Thank you filling out this form completely. It will enable us to help you more effectively. If you have questions at any time, please call us at 916-863-2660. We are happy to help.
INSURANCEINFO
Primary Dental Insurance
Insurance Name:
Insurance Address:
Insurance Phone #:
Group # (Plan, Local or Policy #):
Insured's Name: Relation:
Insured's Birthdate: Insured's SS #:
Insured's Employer:
Insured's Address:
Secondary Dental Insurance
Insurance Name:
Insurance Address:
Insurance Phone #:
Group # (Plan, Local or Policy #):
Insured's Name: Relation:
Insured's Birthdate: Insured's SS #:
Insured's Employer:
Insured's Address:
In the event of an emergency, is there someone who lives near you that we should contact?
His / Her Name: Relation:
Work #: Home #:
MEDICAL HISTORY
Do you have a personal physician?
Physician's Name:
Wk #: Date of last visit:
Your current physical health is:
Are you currently under the care of a physician?
Please Explain:
Are you taking any prescription / ovr-the-ctr drugs?
Please list each one:
Do you smoke or use tobacco in any other form?
For Women: Are you taking birth control pills?
Are you pregnant?
Week#
Are you nursing?
Have you ever had any of the following disease or medical problems? (Please select option that applies)
Anemia/Radiation Treatment
Hemophilia/Abnormal Bleeding
Artificial Bones/Joints/Valves
Hepatitis
Arthritis
High / Low Blood Pressure
Asthma
HIV+ / AIDS
Blood Transfusion
Hospitalized for Any Reason
Cancer / Chemotherapy
Kidney Problems
Congenital Heart Defect
Mitral Valve Prolapse
Diabetes
Psychiatric Problems
Difficulty Breathing
Rheumatic / Scarlet Fever
Drug / Alcohol Abuse
Severe / Frequent Headaches
Emphysema / Glaucoma
Shingles
Epilepsy/Seizures/Fainting
Sickle Cell Disease/Traits
Fever Blisters / Herpes
Sinus Problems
Heart Attack / Stroke
Tuberculosis (TB)
Heart Murmur
Ulcers / Colitis
Heart Surgery
Venereal Disease
Please list any serious condition(s) that you have ever had:Are you allergic to any of the following?
Aspirin
Erythromycin
Penicillin
Codeine
Jewelry / Metals
Tetracycline
Dental Ansthtics
Latex
Other
Please list any other drugs / materials that you are allergic to:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
