Patient Information
Name *
Name
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Email Opt-In
Sex
Marital Status
Birth Date
Birth Date
Section 2
Employment Status
Student Status
Primary Insurance Information
Name of Insured
Name of Insured
Relationship to Insured
Insured Birth Date
Insured Birth Date
Insurance Company Address
Insurance Company Address
Secondary Insurance Information
Name of Insured
Name of Insured
Insured Birth Date
Insured Birth Date
Insurance Company Address
Insurance Company Address
Medical History
Although dental personnel primarily treat the area in and around the mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions truthfully.
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates
Are you on a special diet?
Do you use (smoke, dip, or chew) tobacco?
Women: Are you...
Are you allergic to any of the following?
Do you use controlled substances?
A controlled substance is generally defined as a drug or chemical whose manufacture, possession, or use is regulated by the government (i.e. prescription medications and illegal drugs).
Do you have, or have you had, any of the following?