SSIHIClPatient 10 # _

Patient Name ---,-:-::-;-==-=- _ Last Name

First Name Middle Initial

Address _

City _

State _ Zip _

E-mail _

Sex 0 M 0 F Age _

Birthdale _

o Married o Widowed o Single o Minor

o Separated o Divorced o Partnered for years

Occupation _

Patient EmployerfSchool _

Employer/School Address _

Employer/School Phone ~) _

Spouse's Name _

Birthdate _

SS# _

Spouse's Employer _

W~lO Is responsible for this account? _

Relationship to Patienl _

Insurance Co. _

Group # _

Is patient covered by additional Insurance? 0 Yes 0 No

SUbscriber's Name _

Birthdate _ SS# _

Relationship to Patient _

Insurance Co. _

ASSIGNMENT AND RELEASE , certify that I. and/or my depemlenl(s). have Insurance coverage With

___---.-.-_-----..----__---,._---,--------.---,-.-- and assign directly to Name of Insurance Company(lesl

Dr. all Insurance benefits. If any. otherwise payable to me for services rendered. I understand \/lat \ em financially responsible lor all charges whether or not paid by Insurance. I authorize Ihe use of my signature on all Insurance submissions.

The above-named dentist may use my health care lnformalfon and may disclose such Information to the above-named Insurance Company(les) and theiT agents for the purpose of obtaining payment for services and determining insurance benefits or the benef1ts payable lor related services. This consent will end when my currenl trealment plan Is completed or one year Irom the dale signed below.

Signature of Patient. PeronI. Guardian or Personal Representative

Please prinl name of Patient. Parent. Guardian or Personal Representative

Cell Phone <---JExt

Best lime and place to reach you

Work L-)-------­Spouse's Work L--) _

IN CASE OF EMERGENCY, CONTACT (Specify someone who does nol live In your household.

Rejationship

_

.

_

Work Phone (------J-----------~ _

DENTAL HISTORY

Chew on one side 01 mouth DYes DNo Mouth breathing DYes DNa

Cigarette, pipe, or cigar smoking DYes DNa Mouth pain, brushing o Ves DNa

Former Dentist Clicking or popping Jaw DYes DNa Orthodontic treatment DYes DNa

City/Slate Dry mouth DYes DNo Pain around ear DYes DNo

Dale 01 last dental visit Fingernail biting DYes DNo Periodontal treatment DYes DNo

Date 01 last dental X-rays Food collection between the teeth DYes DNo SenSitivity to cold DYes DNo Place a mark on "yes" or "no· to indicate If you Foreign objects DYes DNo Sensitivity fo heat DYes ONo have had any of the lollowing: Grinding teeth DYes DNa SensitivIty to sWeets DYes DNa Bad breath DYes DNa Gums swollen or tender DYes DNa SensitivIty when biting DYes DNa Bleeding gums DYes DNo Jaw pain or tiredness Dyes DNa Sores or growths In your mouth DYes DNo Blisters on lips or mouth DVes DNo Up or cheek blling DYes DNa How often do you floss? Burning sensation on tongue DYes ONo Loose teeth or broken fillings DYes DNa How often do you brush?

' Date of last visit _

Have you ever taken any of the group of drugs collectively referred to as ufen-phenT These Include combinations 01 lonimin, Adipex. Fastln (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexientluramine). 0 Yes 0 No

Place a mark on "yes" or "no' to indrcate if you have had any of the following:

AIDSIHIV DYes DNo Epilepsy DYes DNa Radjation Treatment DYes DNa Anemia DYes DNa Fainting or dizziness DYes DNa Respiratory Disease DYes DNa Arthritis, Rheumatism DYes DNo Glaucoma DYes DNa Rheumatic Fever DYes DNa Artificial Heart Valves DYes DNa Headaches DYes DNo Scarlet Fever DYes DNa Artificial Joints o Ves DNa Heart Murmur DYes DNo Shortness of Breath DYes DNo Asthma DYes DNa Heart Problems DYes DNo Sinus Trouble DYes DNo Back Problems DVes DNo Hepatitis Type DYes DNa Skin Rash DVes DNo Bleeding abnormally, with Herpes DYes DNo Special Diet DYes DNo

extractions or surgery DYes DNo High BlOod Pressure DYes DNo Stroke DYes DNa Blood Disease DYes DNa Jaundice DYes DNo Swollen Feet or Ankles DYes DNa Cancer DYes DNo Jaw Pain DYes DNo Swollen Neck Glands DYes ONe Chemical Depende (;of DYes DNo Kidney Disease DYes DNo ThyrOid Problems DYes DNo Chemotherapy DYes DNa Uver Disease DYes DNo Tonsillitis DYes DNo CircUlatory Problems DYes DNo low Blood Pressure DYes eNo Tuberculosis DYes DNa Congenital Heart Lesions DYes DNa Mitral Valve Prolapse DYes DNa TlJmor or growth on head Cortisone Treatments DYes DNa Nervous Problems DYes DNo or neck DYes DNa

Cough. persistent or bloody DYes DNa Pacemaker =Ves eNa Ulcer DYes DNa

Diabetes DYes DNo Psychiatric Care DYes DNa Venereal Disease DYes DNo

Empllysema DYes DNa Weight Loss, unexplained DVes DNa

Do you wear contact lenses? DYes DNa

Women:

Are you pregnant? DYes DNa Due date Are you nursing? 0 Yes DNo Taking birth control pills? DYes DNa

ALLERGIES

list any medications you are currently taking and the correlating o Aspirin o Local Anesthetic diagnosis: o Barbiturates (Sleeping pIlls) o Penicillin

o Codeine o Sulfa

o Iodine o Other

Pharmacy Name o Latex

Has there been any change In your health since your last dental appoIntment? 0 Yes 0 No

For what conditions? _

If so, what? _Are you taking any new medications? _

Patient's Signature _ Date _

Doctor's Signature _ Date _

..................................................................................................................................................................................................... I '" ..

Has there been any change in your health since your last dental appointment? 0 Yes 0 No

For what conditions? _

Are you taking any new medications? _ If so, what? --- _

Patient's Signature _ Date _