Patient Information - Please fill out and print this form |
| Name |
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| Address |
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| City, State, Zip |
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| Home Phone |
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| Work Phone |
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| Alt. Phone |
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| Email |
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| Social Security Number |
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| Date of Birth |
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| Sex |
Male
Female |
| School (if student) |
|
| Relationship to Insurance Holder |
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Alternate Address: |
| Address |
|
| City, State, Zip |
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Referred By:
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| Name |
|
| Address |
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| City, State, Zip |
|
| Phone |
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Patient's Medical History:
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| Primary Care Physician |
|
| Address |
|
| City, State, Zip |
|
| Phone |
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Please read very carefully and check all of the following items that are appropriate:
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I should take antibiotics prior to dental appointments since I have or
have had RHEUMATIC FEVER, SCARLET FEVER, HEART MURMUR, VALVULAR HEART
DISEASE, ARTIFICIAL HEART VALVE, or ARTIFICIAL HIP or KNEE. |
I am
allergic to:
|
I am taking COUMADIN or BLOOD THINNERS. |
I am unable to to tolerate EPINEPHRINE in local anesthesia. |
I am a SMOKER:
packs per day. |
I have been HOSPITALIZED during past two years. If so, why?
|
Please write DRUGS/MEDICATIONS you have taken during the past
year:
|
Please check each of the following which you have or have had:
|
|
Patient's Dental History: |
I have (or have had):
Full mouth DENTAL RADIOGRAPHS (X-RAYS) within the past two years. They were
done by Dr.
Temporomandibular Joint (TMJ) click
Orthodontic treatment. It was done by Dr.
My jaw lock open.
My jaw lock closed.
Please describe your chief complaint or concern:
|
Please Sign and Date Below: |
I have read and understand all the above questions. The above medical
history is accurate and complete. I also understand that there is continuous
video recording of the interior and exterior of this facility.
Signed:
Date:
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