_____________ Home Phone (__) Cell Phone (__) _

Last Name First Name Middle Initial E-mail

SS/HIC/Patient ID #

_

_

State _ Zip _

D F Age Birthdate _ D Married D Widowed D Single D Minor

D Separated D Divorced D Partnered for years

Patient Employer/School _ Occupation _

Employer/School Address _ Employer/School Phone (__) _

Whom may we thank for referring you? _

In case of emergency who should be notified? _ Phone (__) _

Is patient covered by additional insurance?

Subscriber Name

DYes

_ Relation to Patient Birthdate _

Address (If different from patient's)

State

_ Phone (__)

Zip

_

_

Subscriber Employed by

Insurance Company

_

_

Business Phone (

Soc. Sec. #

Group #

)

_ Subscriber # _

_

_

Names of other dependents covered under this plan _

Please Complete Both Sides

Date of last dental care _

Former Dentist _ Date of last dental X-rays _

Check ( ./ ) if you have had problems with any of the following:

o Bad breath 0 Grinding teeth o Sensitivity to hot

o Bleeding gums 0 Loose teeth or broken fillings o Sensitivity to sweets

o Clicking or popping jaw 0 Periodontal treatment o Sensitivity when biting

o Food collection between teeth 0 Sensitivity to cold o Sores or growths in your mouth

How often do you brush? _

Date of Last Visit _

Have you ever taken any of the group of drugs collectively referred to as ''fen-phen?'' These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). 0 Yes 0 No

Have you had any serious illnesses or operations? 0 Yes 0 No If yes, describe _

Have you ever had a blood transfusion? 0 Yes 0 No If yes, give approximate dates _

(Women) Are you pregnant? 0 Yes 0 No Nursing? 0 Yes ONo Taking birth control pills? 0 Yes ONo

Check ( ./ ) if you have or have had any of the following:

o Anemia 0 Cortisone Treatments o Hepatitis o Scarlet Fever

o Arthritis, Rheumatism 0 Cough, Persistent o High Blood Pressure o Shortness of Breath

o Artificial Heart Valves 0 Cough up Blood o HIV/AIDS o Skin Rash

o Artificial Joints 0 Diabetes o Jaw Pain o Stroke

o Asthma 0 Epilepsy o Kidney Disease o Swelling of Feet or Ankles

o Back Problems 0 Fainting o Liver Disease o Thyroid Problems

o Blood Disease 0 Glaucoma o Mitral Valve Prolapse o Tobacco Habit

o Cancer 0 Headaches o Pacemaker o Tonsillitis

o Chemical Dependency 0 Heart Murmur o Radiation Treatment o Tuberculosis

o Chemotherapy 0 Heart Problems o Respiratory Disease o Ulcer

o Circulatory Problems 0 Hemophilia o Rheumatic Fever o Venereal Disease

MEDICATIONS ALLERGIES List medications you are currently taking:

I certify that I, and/or my dependent(s), have insurance coverage with _____..------.,------,-------....,.,.------ and assign directly to Name of Insurance Company(ies)

Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

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

Signature of Patient, Parent, Guardian or Personal Representative Date

Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

Payment is due in full at time of treatment unless prior arrangements have been approved.