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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.