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To help w meet all your dental healthcare needs, pleasefill out this form letely in ink. Ifyou have any questions or need assistance, please aslz us -

we will be happy to help.

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Patient 1

SS#/SrA -

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Name

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Birthdate.

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- Home P State,'

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Email

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Minor C 1 Single i vorced [ - Cell Phone -

7 Widowed Sej I I - ---- - lrt

T m e U Time LJ 3LUU

Patien

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t or ParentlGwrrdian's Employer Work PI State/

ss Address Prov. -

: or Parent/Guardianls Name Employer Work Pi

I May W e h k f o r Referring You?

I to Contact in Case ofEmergency Phone -

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Person

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of Person Responsible for this Account - to Patio ship l t .- - hone -

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- Home Pi

's License # Bii-thdate Financial Insti

- Cell Pho

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Is this Yer Work Phone Person Currently a Patient in our Office? [7 Yes 0 No

ur convenience, we offev the following methods ofpayment. Please check the option you prefer. Payment infi*ll at each a,

sh Personal Check Credit Card V~SA Mastercard I wish to discuss the office's pa

ppointment

yment poli'

Relation. - to Patien

ship It - Name of Imred -

n:-&l- .J ate SS#/SlN Date EmVruYru DLILrUi

Name

Addre!

of Employer Union or Local # Work Phone State/ Zip/

s ofEmployer City Prov. P. C.

- Policy/m state,'

- Prov. -

Insurance Compc

Ins. Co. Address -

Hnw MI : Annual LIB

E THE F(

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COMPLE' IF YES, YOUHAV E ANY AD I Yes C Relation

- to Patien "LLY !t -

ployed - ,n-0

- Date E y ate - - .

- Work Ph,. ., - Statef Zil

- Prov. P.

of Employer-

n of Employer-

nce Company - j. Address

4wh is your Deductib

... -1ty - ;roup # -

City-

~ c h Have You Used?-

Over Please

Ins. cc Howh

Prov. -

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Patient Medicd History Physician )@ce Phone " , ofLastExam

Yes N o :you allerg eyou had any reactions to thefollowing? ................ 0 0 Yes NO

:a1 Anesthencs \e.g. ~uavocain) ..................................... licillin or m .............. 17 fa Drugs ... .............. vbiturates .. ..............

I7 fatives .............................................................................. ine .................................................................................. . . xnn ................................................................................. y Metals (e.g. nickel, mercury, etc.) ............................... ac Rubber ........................................................................ zer (please list)

I7

you have a persistent cough or throat clearing not ociated with a known illness (lasting more than 3 weeks) [7

- ume ic to or hav 9. Art

T nt 1. Are you under medical treatment now? ....

2. Have you ever been hospitalkedfor any surgical operation c Ifyes, please scplail

t the last 5: years? ......

-- - Per Su! Bal n

ttibiotics ....

Jecj lod As1 An:

3. Are you taking any medicatior including non-prescription mec

1(S) licine? ........

Ijyes, what medicatiin(s) are, you taking:

La1 Otl

10. Do ncc,

4. Have you ever taken Fen-PhenAZedux? ........................

5. Do you use tobacco? .......................................................................

6. Do you use controlled substances? .............................

7. Are you wearing contact lenses? ................................... )men Only: 4re you prt 4re you nu]

...... :gnant or think you may be pregnant? [7 rsing? ............................................................

............................. C ) Are you taking oral contraceptives? 17 8. Do you have or have you had any of thefollowing?

Yes N o

I7 17

17

Yes N o

I7

Yes N o I7

17

High Blood Pressure ...................... Ieart Disea Chest Pains .................................... Easily Winded ............................... Stroke ............................................. Hay Fever /Allergies .................... Tuberculosis ................................... Radiation Therapy ........................

...................................... Glaucoma Recent Weight Loss ....................... Liver Disease ................................. Heart Trouble ................................ Respiratory Problems .................... Mitral Valve Prolapse ................... Other

Heart Attack ................................... Rheumatic Fever ............................ Swollen Ankles ...............................

Cardiac Pacemaker ........................ Heart Murmur ............................... Angina ............................................ Frequently Tired ............................ Fainting / Seizures .........................

Asthma ............................................ Low Blood Pressure ....................... Epilepsy / Convulsions .................. Leukemia ........................................

Anemia ........................................... ................................... Emphysema

............................................ Cancer Arthritis ..........................................

Diabetes .......................................... Kidney Diseases ............................. AlDS or HW Infection ................... Thy void Problem ...........................

Joint Replacement or lmplant ....... Hepatitis /Jaundice ........................ Sancally Transmitted Disease ...... Stomach Troubles / Ulcers ............

Patient Dental History Name of Previous Dentist and Location Date of Last Exam

Yes

C7

Yes 1. Do your gums bleed while brushing orpossing? ......... 2. Are your teeth sensitive to hot or cold liqui&$oods? .................. 3. Are your teeth sensitive to sweet or sour liquids/foods? .............. 4. Do youfeel pain to any ofyour teeth? .......................................... 5. Do you have any sores or lumps in or nearyour mouth? .......... 6. Have you had any head, neck or jaw injuries? ........................... 7. Have you ever experienced any of the following

problems in your jaw? Clicking ....................................................................... Pain (joint, ear, side offace) ...................................... Dificulty in opening or closing ................................. Dificulty in chewing ..................................................................

.................................. 8. Do you havefvequent headaches? 9. Do you clench or grind your teeth? ................................ 10. Do you bite your lips or cheeksfrequently ? .................. 11. Have you ever had any dificult extractions

in thepast? ....................................................................... U U 12. Have you ever had any prolonged bleeding

foIlowing sctractions? ..................................................... I7 13. Have you had any orthodontic treatment? ..................... [7 14. Do you wear dentures or partials? ................................

Ifyes, date of placement 15. Have you ever received oral hygiene instructions

regarding the care ofyour teeth and gums? ................... 16. D( our smile? ..................................................

- - >you likey

Atcthovizution and I certih 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 dangerow 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 eriod of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the &tist or dental group insurance benefits otherwise pczyable 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 behalfor I

X Signature of patient (or parent/guardian ifminor-)

Doctor's Comments

Signature Date 163061051-1014