Office open on Monday Wednesday Friday Saturday from 9 am to 6 pm. Please call (408) 223-9600 to make an appointment.

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    Welcome

    Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink.If you have any questions or need assistance, please ask us - we will be happy to help.

    MinorSingleMarriedDivorcedWidowedSeparated

    Full TimePart Time

    Responsible Party

    YesNo

    For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

    CashPersonal CheckCredit CardVISAMaster CardI wish to discuss the office's payment policy.


    YesNo

    If yes complete the following

    Patient Medical History

    1. Are you under medical treatment now.....YesNo
    2. Have you ever been hospitalized for any surgical operation
    or serious illness within the last 5 years?.....
    YesNo
    If yes, please explain
    3. Are you taking any medication(s) including non-prescription
    medicine?.....
    YesNo If yes, what medication(s) are you taking
    4. Have you ever taken Fen-Phen/Redux?.....YesNo
    5. Have you ever taken Fosamax, Boniva, Actonel or any cancer
    medications conatining bisphosphonates?.....
    YesNo
    6. Have you taken Viagra, Revatio, Cialis or Levitra in last
    24 hours?.....
    YesNo
    7. Do you use tobacco?.....YesNo
    8. Do you use controlled substances?.....YesNo

    9. Are you wearing contact lenses.....YesNo
    10. Are you allergic to or have you had any reactions to the following?
    Local Anesthetics (e.g. Novocain).....
    YesNo
    Penicillin or any other Antibiotics.....YesNo
    Sulfa Drugs.....YesNo
    Barbiturates.....YesNo
    Sedatives.....YesNo
    Iodine.....YesNo
    Aspirin.....YesNo
    Any Metals (e.g. nickel, mercury, etc.).....YesNo
    Latex Rubber.....YesNo
    Other (please list).....
    11. Do you have a persistent cough or throat clearing not
    associated with a known illness (lasting more than 3 weeks)?.....
    YesNo

    12. Women Only :

    a) Are you pregnant or think you may be pregnant?...YesNo
    b) Are you nursing?....YesNo c) Are you taking oral contrceptives?.....YesNo

    13. Do you have or have you had any of the following?

    High Blood Pressure.....YesNo
    Heart Attack.....YesNo
    Rheumatic Fever.....YesNo Swollen Ankles.....YesNo
    Fainting/Seizures.....YesNo
    Asthma.....YesNo
    Low Blood Pressure.....YesNo Epilepsy/Convulsions.....YesNo
    Leukemia.....YesNo
    Diabetes.....YesNo
    Kidney Diseases.....YesNo
    AIDS or HIV Infection.....YesNo
    Thyroid Problem.....YesNo

    Heart Disease.....YesNo
    Cardiac Pacemaker.....YesNo
    Heart Murmur.....YesNo Angina.....YesNo
    Frequently Tired.....YesNo
    Anemia.....YesNo
    Emphysema.....YesNo
    Cancer.....YesNo
    Arthritis.....YesNo
    Joint Replacement or Implant.....YesNo
    Hepatitis/Jaundice.....YesNo
    Sexually Transmitted Disease.....YesNo
    Stomach Troubles/Ulcers.....YesNo

    Chest Pain.....YesNo
    Easily Winded.....YesNo
    Stroke.....YesNo
    Hay Fever/Allergies.....YesNo
    Tuberculosis.....YesNo
    Radiation Therapy.....YesNo
    Glaucoma.....YesNo
    Recent Weight Loss.....YesNo
    Liver Disease.....YesNo
    Heart Trouble.....YesNo
    Respiratory Problems.....YesNo
    Mitral Valve Prolapse...YesNo
    Other...

    Patient Dental History

    1. Do you gums bleed while brushing or flossing?.....YesNo
    2. Are your teeth sensitive to hot or cold liquids/foods?.....YesNo
    3. Are your teeth sensitive to sweet or sour liquids/foods?.....YesNo
    4. Do you feel pain to any of your teeth?.....YesNo
    5. Do you have any sores or lumps in or near your mouth?.....YesNo
    6. Have you had any head, neck or jaw injuries?.....YesNo
    7. Have you ever experienced any of the following problems in your jaw?
    Clicking.....YesNo
    Pain(joint, ear, side of face)......YesNo
    Difficulty in opening or closing.....YesNo
    Difficulty in chewing.....YesNo

    8. Do you have frequent headaches?.....YesNo
    9. Do you clench or grind your teeth?.....YesNo
    10. Do you bite you lips or cheeks frequently?.....YesNo

    11. Have you ever had any difficult extractions

    in the past.....YesNo

    12. Have you ever had any prolonged bleeding following

    extractions?.....YesNo
    13. Have you had any orthodontic treatment?.....YesNo
    14. Do you wear dentures or partials?.....YesNo
    If yes, date of placement

    15. Have you ever received oral hygiene instructions

    regarding the care of your teeth and gums.....YesNo
    16. Do you like your smile?.....YesNo

    Authorization and Release


    I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party pavors and/or health practitioners. authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise pavable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.