Today’s Date *
Last Name *
First Name *
Middle Initial
Preferred Name
Home Address
City/State/Zip
State *
Zip Code *
Home Phone
Alternate Phone
Email
Marital Status MinorSingleMarriedDivorcedWidowedSeparated
Sex * MaleFemale
Age *
Birthdate *
Employed By
Occupation
Employer Address
Work Phone
Spouse/Parent Name
Spouse/Parent Birthdate
Who is responsible for this account?
Relationship to Patient
Social Security #
Spouse/Parent Social Security #
Name of Dental Insurance Company
Group Number
In case of emergency, notify:
Phone
Whom may we thank for referring you?
Physician’s Name
Date of Last Physical
Have you ever had any of the following? (check all that apply)
Heart Problems
Epilepsy
Special diet
High blood pressre
Headaches
Swollen neck glands
Low blood pressure
Hepatitis, jaundice or liver disease
Rheumatic fever
Circulatory problems
Cancer
Sinus problems
Nervous problems
Psychiatric care
HIV/AIDS or other immonosuppresive disorders
Radiation treatment
Chronic diarrhea
Artificial heart valves or joints
Allergies to anesthetics
Thyroid disease
Recent weight loss
Allergies to medicine or drugs
Stroke
Back problems
General allergies
Ulcer
Diabetes
Blood disease
Venereal disease
Chemical dependency
Respiratory disease
Arthritis
Hemophilia
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 *
4 + 4 = ? Please prove that you are human by solving the equation *
