Today’s Date *
Last Name *
First Name *
Zip Code *
Marital Status MinorSingleMarriedDivorcedWidowedSeparated
Sex * MaleFemale
Who is responsible for this account?
Relationship to Patient
Social Security #
Spouse/Parent Social Security #
Name of Dental Insurance Company
In case of emergency, notify:
Whom may we thank for referring you?
Date of Last Physical
Have you ever had any of the following? (check all that apply)
High blood pressre
Swollen neck glands
Low blood pressure
Hepatitis, jaundice or liver disease
HIV/AIDS or other immonosuppresive disorders
Artificial heart valves or joints
Allergies to anesthetics
Recent weight loss
Allergies to medicine or drugs
Do you have any drug allergies or have you ever had an adverse reaction to any medication? NoYes
If so, please describe
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. NoYes
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time? NoYes
If so, what
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). NoYes
Are you under the care of a physician? NoYes
For what conditions?
If patient is a child, what is his/her weight?
(Women) Do you suspect that you are pregnant? NoYes
Are you nursing? NoYes
Is there anything else we should know about your medical history?
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
I Agree *
2 + 0 = ? Please prove that you are human by solving the equation *
32 South Main Street
Topsfield, Massachusetts 01983