DENTAL REGISTRATION AND HISTORYPATIENT INFORMATION DENTAL INSURANCE

Date _ Who is responsible for this account? _

SS/HIC/Patient ID # _ Relationship to Patient _

Patient Name _Last Name

Insurance Co. _

Address _

E-mail _

Sex 0 M 0 F Age _

SS# _

__________________ and assign directly toName of Insurance Company(ies)

Group # _

Is patient covered by additional insurance? 0 Yes 0 No

Subscriber's Name _

Relationship to Patient _

Insurance Co. _

Group # _

ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s), have insurance coverage with

Birthdate _

o Minor

Middle Initial

Zip _

o Single

o Partnered for years

oWidowed

o Divorced

First Name

City _

State _

Birthdate _

o Married

o Separated

Patient Employer/School _

Occupation _

Employer/School Address _

Dr. all insurance benefits, ifany, otherwise payable to me for services rendered. I understand that I amfinancially responsible for all charges whether or not paid by insurance. I authorizethe use of my signature on all insurance submissions.

Employer/School Phone (__ l _Spouse's Name _

The above-named dentist may use my health care information and may disclosesuch information to the above-named Insurance Company(ies) and their agentsfor the purpose of obtaining payment for services and determining insurancebenefits or the benefits payable for related services. This consent will end whenmy current treatment plan is completed or one year from the date signed below.

Birthdate _

SS# _Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal RepresentativeSpouse's Employer _

Whom may we thank for referring you? _Date Relationship to Patient

PHONE NUMBERSHome (__ l _ Work (--l-------- Ext Cell Phone (__ l _

Spouse's Work ( l Best time and place to reach you _

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.l

Name _ Relationship _

Home Phone ( l _ Work Phone (__ l _

DENTAL HISTORY

(Vers.D2SSS04)

Former Dentist _

Date of last dental visit _

Reason for today's visit _ Burning sensation on tongue DYes DNo Mouth breathing DYes DNo

Chew on one side of mouth DYes DNo Mouth pain, brushing DYes DNo

Cigarette, pipe, or cigar smoking DYes DNo Orthodontic treatment DYes DNo

Clicking or popping jaw DYes DNo Pain around ear DYes DNo

Dry mouth DYes DNo Periodontal treatment DYes DNo

Fingernail biting DYes DNo Sensitivity to cold DYes DNo

Food collection between the teeth DYes DNo Sensitivity to heat DYes DNo

Foreign objects DYes DNo Sensitivity to sweets DYes DNo

Grinding teeth DYes DNo Sensitivity when biting DYes DNo

Gums swollen or tender DYes DNo Sores or growths in your mouth DYes DNo

Jaw pain or tiredness DYes DNo How often do you floss?Lip or cheek biting DYes DNoLoose teeth or broken fillings DYes DNo How often do you brush?

- 0 V E R - #20558- <l:> 2004MedicalArtsPress·'-800-328-2179

DNo

DNo

DNo

DYes

DYes

DYes

City/State _

Date of last dental X-rays _

Place a mark on "yes" or "no" to indicate if youhave had any of the following:

Bad breath

Bleeding gums

Blisters on lips or mouth

~HEALTH HISTORY-Physician's Name Date of last visitHave you ever taken any of the group of drugs collectively referred to as "fen-phen?"These include combinations of lonimin, Adipex, Fastin (brandnames of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).0 Yes DNoPlace a mark on ''yes'' or "no" to indicate if you have had any of the following:AIDS/HIV DYes DNo Epilepsy DYes DNo Respiratory Disease DYes DNoAnemia DYes DNo Fainting or dizziness DYes DNo Rheumatic Fever DYes DNoArthritis, Rheumatism DYes DNo Glaucoma DYes DNo Scarlet Fever DYes DNoArtificial Heart Valves DYes DNo Headaches DYes DNo Shortness of Breath DYes DNoArtificial Joints DYes DNo Heart Murmur DYes DNo Sinus Trouble DYes DNoAsthma DYes DNo Heart Problems DYes DNo Skin Rash DYes DNoBack Problems DYes DNo Hepatitis Type DYes DNo Special Diet DYes DNoBleeding abnormally, with DYes DNo Herpes DYes DNo Stroke DYes DNo

extractions or surgery High Blood Pressure DYes DNo Swollen Feet or Ankles DYes DNoBlood Disease DYes DNo Jaundice DYes DNo Swollen Neck Glands DYes DNoCancer DYes DNo Jaw Pain DYes DNo Thyroid Problems DYes DNoChemical Dependency DYes DNo Kidney Disease DYes DNo Tonsillitis DYes DNoChemotherapy DYes DNo Liver Disease DYes DNo Tuberculosis DYes DNoCirculatory Problems DYes DNo Low Blood Pressure DYes DNo Tumor or growth on head or DYes DNoCongenital Heart Lesions DYes DNo Mitral Valve Prolapse DYes DNo neckCortisone Treatments DYes DNo Nervous Problems DYes DNo Ulcer DYes DNoCough, persistent or bloody DYes DNo Pacemaker DYes DNo Venereal Disease DYes DNoDiabetes DYes DNo Psychiatric Care DYes DNo Weight Loss, unexplained DYes DNoEmphysema DYes DNo Radiation Treatment DYes DNo

Do you wear contact lenses? 0 Yes DNoWomen:

Are you pregnant? 0 Yes DNo Due date Are you nursing? 0 Yes DNoTaking birth control pills? 0 Yes DNo

MEDICATIONS ALLERGIESList any medications you are currently taking and the correlating diagno- o Aspirin o Local Anestheticsis: o Barbiturates (Sleeping pills) o Penicillin

o Codeine o Sulfa

Pharmacy Name o Iodine o Other

Phone (__ ) o Latex

UP D ATE S (To be filled in at future appointments)

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

For what conditions? _

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

Patient's Signature Date _

Doctor's Signature. Date _

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 _

Doctor's Signature Date _