Mitral Valve
Prolaspe

Parathyroid
Disease

Heart Attack/
Failure

Do You Have, Or Have Had, Any Of The Following?

AIDS/Positive

Anaphylaxis

Local Anesthetics

Are You Allergic To Any Of The Following?

Aspirin

Women Are You:

Pregnant/Trying

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a 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.

Are you under a physician's care now?

PATIENT PAYMENT DUE AT TIME OF SERVICE, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. I UNDERSTAND THAT A FINANCE CHARGE MAY BE ADDED TO AN ACCOUNT OPEN OVER 60 DAYS.

By checking the box, I acknowledge that I have read and understand the above statement.

We would appreciate it if you would take a few moments to fill this form out prior to your first visit. If you prefer, you may download and print a copy to bring in by clicking here.

First Name

M.I.

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

E-mail Address

Phone

Bold = Required field

Patient Information

Date

Cell Phone

Date Of Birth

SSN#

DL#

Spouse's/Parent Name

Employer/School

Employer/School Address

Employer/School Phone

Whom may we thank for referring you?

Family/Insurance Information

Person Responsible For This Account

Relationship to Patient

Address

Business Address

SSN#

Insurance Company Name

Phone

Company Providing Insurance

Insured Person's Name

Name(s) of Other Family Members

If Yes, Please Explain

Have You Ever Been Hospitalized Or Had A Major Operation?

If Yes, Please Explain

Have You Ever Had A Serious Head Or Neck Injury?

If Yes, Please Explain

Are You Taking Any Medications, Pills, Or Drugs?

If Yes, Please Explain

Have You Ever Taken Phen-Fen or Redux?

Are You On A Special Diet?

If Yes, Please Explain

Do You Use Tobacco?

Do You Use Controlled Substances?

Nursing

Taking Oral Contraceptives?

Penicillin

Codeine

Acrylic

Metal

Latex

Other

Please Explain

Alzheimer's
Disease

Anemia

Angina

Arthritis/
Gout

Artificial
Heart Valve

Artificial Joint

Asthma

Blood
Disease

Blood
Transfusion

Breathing
Problems

Bruises
Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores

Congenital
Heart Disease

Convulsions

Cortisone
Med's

Diabetes

Drug
Addiction

Easily
Winded

Emphysema

Epilepsy or
Seizures

Excessive
Bleeding

Excessive
Thirst

Fainting
Spells

Frequent
Cough

Frequent
Diarrhea

Frequent
Headaches

Genital
Herpes

Glaucoma

Hay Fever

Heart
Murmur

Heart Pace
Maker

Heart Trouble/
Disease

Hemophilia

Hepatitis A

Hepatitis
B or C

Herpes

High Blood
Pressure

Hives or
Rash

Hypoglycemia

Irregular
Heartbeat

Kidney
Problems

Leukemia

Liver
Disease

Low Blood
Pressure

Lung
Disease

Pain in
Jaw Joints

Psychiatric
Care

Radiation
Treatment

Recent
Weight Loss

Renal
Dialysis

Rheumatic
Fever

Rheumatism

Scarlet
Fever

Shingles

Sickle
Cell

Sinus
Trouble

Spina
Bifida

Stomach
Disease

Stroke

Swelling
of Limbs

Thyroid
Disease

Tosillitis

Tuberculosis

Tumors or
Growths

Ulcers

Veneral
Disease

Yellow
Jaundice

Have You Ever Had Any Serious Illness Not Listed Above?

If Yes, Please Explain

Comments

Group ID #