Patient Information Patient's Name__________________________ Birthdate________________ Address__________________________________Home Phone_______________ __________________________________Work Phone_______________ SSN____________________________ Occupation________________________ Spouse's Name________________________ Occupation__________________ Person responsible for account____________________________________ Birthdate_____________SSN_________________________________________ Employer__________________________________________________________ Address___________________________________________________________ Ins.Co._________________________________Address___________________ Group number______________________________________________________ AUTHORIZATION, RELEASE, AND AGREEMENT TO PAY FOR SERVICES RENDERED I agree to be responsible for payment of all services rendered on behalf of myself and my dependents. I authorize the dentist to release any information to third party payors, collection agencies, and/or other health practitioners. This may include the diagnosis and records of any examination or treatment rendered. X__________________________________Date___________________________ I authorize and hereby request my insurance company to pay, directly to the dentist, insurance benefits otherwise payable 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 behalf or on behalf of my dependents. X____________________________________Date_________________________ Were you referred to us by anyone? If so, who?___________________ Health Information (no) (yes) Do you have a health problem? If yes, explain__________________________ ____ ____ My last physical exam was on_____________________ Name of Physician__________________ Are you under a doctor's care? If yes, explain__________________________ Are you taking any drugs or medicine? ____ ____ If yes, list in margin. Have you reacted adversely to: a. local anesthetics ____ ____ b. penicillin or any antibiotics ____ ____ c. sulfa drugs ____ ____ d. barbiturates, sedatives ____ ____ e. aspirin ____ ____ f. codeine or other narcotics ____ ____ g. any other medication ____ ____ Are you allergic to anything? ____ ____ If yes, what?____________________________ Do you have any emotional, nervous, mental problems? If yes, what?__________________ ____ ____ Do you bleed a great deal after tooth extraction or cut? ____ ____ Are you wearing contact lenses? ____ ____ Do you have a pacemaker? ____ ____ Have you had Radiation Treatments or Chemotherapy? ____ ____ Have you ever had any problems with any of the following? (check if answer is yes) ___Heart ___Headaches ___Fainting ___Asthma ___Kidney ___Seizures ___Cancer ___Diabetes ___Speech ___Frequent colds ___Osteoporosis ___Sinus ___Ulcers ___Arthritis ___Stroke ___Liver ___Blood Pressure ___Dizziness ___Beestings ___Rheumatic Fever ___Heart Murmur ___Anemia ___Blood Disorder ___Joint Replacement INFECTIOUS DISEASES Have you, any members of your family or intimate friends had contact with any person with the following diseases? (circle) hepatitis, tuberculosis, AIDS, venereal diseases, herpes Are you considered to be in a high risk group for any of these? Yes____ No____ Women: Please tell us when you are pregnant. Have you EVER taken Fosamax or other bisphosphonate? Dental History When was your last visit to the dentist?__________________________ For records transfer, please list the name and address of your previous dentist: _______________________________________________ _______________________________________________ Have you had a toothache recently?________________________________ If yes, explain___________________________________________ Have you noticed:(circle problem areas) Bleeding or sore areas in mouth Bad breath Spaces developing between teeth Food catching between teeth Teeth sensitive to hot, cold, sweets Swelling or lump in mouth Are you wearing any dental appliances?____________________________ Have you ever bumped your teeth?__________________________________ Have you had any serious problems associated with any previous dental treatment?_________________________________________________ How do you feel about dental treatment? ___no problem ___worry about it ___very fearful Please indicate by your signature that the above information is accurate to the best of your knowledge and that you assume full responsibility for any misinformation which results in treatment complications for you or transmission of communicable diseases to you dentist, staff, or other patients. X____________________________________Date_________________________