We are pleased to welcome yoa to our practice.

'l - completely r$ yoa can. Ifyou haue questions wdll be

glad to help you. We looh foryord to uorbing uith lou,iyrnaintain ng yoar dcntal heahh.

Please tahe a few minutes to fill oat tbis fotm as

Phone ( ) Alt. Phone ( )

SS/HlC/Patient lD #Middle lnitial

State

-

Zip

n Widowed [l Single I Minor! Divorced fl Partnered for

-

years

Employer/School Phone (-)

Whom may we thank for referring you?

Patierut lnformatian

Last Name

Address

City

SexlM nF Age-Bi I Marriedfl Seoarated

OccupationPatient Employer/School

Employer/School Address

ln case of emergency who should be notified ? Phone ( )

Primary lnsurd,ncePerson Responsible for Account

Last Name First Name Middle lnitial

Relation to Patient

Address (lf different from patient's)

Birthdate Soc. Sec. #

Phone ( )

State _ Zip

Person Responsible Employed by Occupation

Business Phone ( )

City

Business Address

lnsurance Company

Contract #

Names of other dependents covered under this plan

Subscriber Name

Address (lf different from patient's)

Group # Subscriber #

fl No

Birthdate Relation to Patient

Phone ( )

State

--

Zip

Subscriber Employed by Business Phone ( )

lnsurance Company

Contract #

Soc. Sec. #

Group #

Names of other dependents covered under this plan

Additional lnsararrcels patient covered by additional insurancel I Yes

City

Rev.3/2012 Please Complete Both Sides

Subscriber #

#2 1 786 - Ol\.4edical Arts Press 1 -800-328 -217 I

Check ( / ) if you have had problems with any of the following:

E Bad breath n Grinding teeth [1 Sensitivity to hot

! Bleeding gums [] Loose teeth or broken fillings I Sensitiviry to sweets

[] Clicking or popping law I Periodonal treatment I Sensitivity when biting

I Food collection between teeth E Sensitivity to cold I Sores or growths in your mouth

Dental HistoryReason for Today's Visit Date of last dental care

Former Dentist Date of last dental X-rays

How often do you floss? How often do you brush?

Medical HistoryPhysicianl Name Date of LastVisit

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. IYes E tto

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). EYes n No

Have you had any serious illnesses or operations? [Yes I No lf yes,describe

Have you ever had a blood transfusionl nYes I No lf yes,give approximate dates

(Women)Are you pregnantl EYes E No Nursing? IYes I No Taking birth control pills? IYes E No

Check ( / 1lt you have or have had any of the following:

EAnemia E Cortisone Treatments ! Hepatitis n Scarlet Fever

EArthritis, Rheumatism n Cough, Persistent n Higl-r Blood Pressure E Shortness of Breath

nArtificial HeartValves I Cough up Blood n HIViAIDS

I Artificial Joints

n Asthma

I Back Problems

n Blood Disease

n Cancer

tr Diabetes

! Epilepsy

I Fainting

I Glaucoma

n Headaches

n Jaw Pain

[f Kidney Disease

T Liver Disease

E Skin Rash

n Stroke

[1 Swelling of Feet orAnkles

I Thyroid Problems

I Chemical Dependency E Heart Murmur

n Chemotherapy [] Heart Problems

I Circulatory Problems [1 Hemophilia

MEDICATIONS: List medications you are currently taking:

n Mitral Valve Prolapse trTobacco Habit

E Pacemaker J Tonsillitis

X Radiation Treatment n Tuberculosis

I Respiratory Disease n Ulcer

I Rheumatic Fever nVenereal Disease

ALLERGIES

AuthorizationI certify that l, and/or my dependent(s), have insurance coverage with

Name of lnsurance Company(ies)and assign directly to \i

all insurance benefits, if any, otherwise payable to me for services rendered. I understandthat I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance

submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named lnsurance Company(ies)

and their agents for the purpose of obtaining paymenr for services and determining insurance benefits or the benefits payable for related

services.This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

Payment is due in full at time of treatment unless prior arrangements have been aPProved.