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Date of Birth* Emergency Contact Name And Phone Number* Who Is Your Family Physician* Person responsible for this account (if not patient): name, phone number and relationship* Dental Insurance Information: Please list 1) Insurance Company 2) Policy # 3) Subscriber ID# 4) If the Insured is not the patient the Name of the Insured, their DOB, their Employer and their relationship to the patient.Please list the details if you have additional Insurance.Please list all medications, dosages and reasons for taking them. Include all prescriptions, vitamins and recreational drugs. If none please write N/ADo you have any allergies?* Penicillin Codeine Latex Local Anesthetic Other No Allergies If you answered "other" to allergies, what allergies do you have? Do you have any of the following?* Sensitive teeth Worn/chipped/broken teeth Bleeding gums Headaches TMJD/Facial pain Bad Breath Sleep Apnea None of the above Have you ever experienced the following?* High/Low blood pressure Heart Attack Joint Replacement Hepatitis Anemia Heart Disease Pacemaker Kidney Disease Emphysema Asthma Fainting/Seizures Epilepsy AIDS/HIV Cancer Bleeding problems/bruise easily Chest Pains Diabetes Stroke Tuberculosis Other Are you currently pregnant Healthy with no history of illness If you answered "Other" to "Have you ever experienced the following", please list anything that you feel is important for us to know. Do you have osteoporosis?* Yes No Did your doctor prescribe medication(s) for your osteoporosis, low bone density/ osteopenia or bone health?* Yes No N/A If you answered "Yes" to the last question, the prescribed medications by my doctor are: When was the last visit to the dentist? Have you had dental xrays in the last 2 years? Are you happy with your smile and teeth? Authorization and Release: I certify that I have accurately answered the questions above. I understand that providing incorrect information can be dangerous 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 period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group 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 my dependents. By checking this box below I agree to this statement.* I consent to this authorization and release.
