4620 E Douglas, Suite 100Wichita, KS 67208

Please fill out these formscompletely. The better we

communicate, the better we can care for you.

PAUDEN_111 (11/15)

Terra Pauly D.D.S

The benefits of a happy,healthy smile are immeasurable! Our goal is tohelp you reach and maintain maximum oral health.

About YouTodays Date:

Name:

I prefer to be called: Male Female

Birth date: Age: SS#:

Home Address

Single Widowed Married Divorced Separated

Home#: Work#:

Cell#: Email:

Employer:

Employer’s Address:

How long there? Occupation:

Where & when are best times to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Previous / Present Dentist:

Last Visit Date:

Last First MI Mr. Mrs. Ms. Dr.

APT/CONDO#

City State Zip

1.Primary Dental Insurance

Insurance Company Name:

Insurance Co. Address:

Insurance Co. Phone#:

Group # (Plan, Local or Policy #):

Insureds Name: Relation

Insureds Birthday: Insureds SS#:

Insureds Employer:

Orthodontic Coverage? Yes No

Secondary Dental Insurance

Insurance Company Name:

Insurance Co. Address:

Insurance Co. Phone#:

Group # (Plan, Local or Policy #):

Insureds Name: Relation

Insureds Birthday: Insureds SS#:

Insureds Employer:

Orthodontic Coverage? Yes No(PLEASE CIRCLE)

Spouse Information2.Name:

Employer:

Work#: Cell#:

D.O.B.: SS#:

Person Responsible for Accounts:

Work #: Ext HM#:

Billing Address:

Relationship: SS#:

Employer: DL#:

Dental Insurance3.

In the event of an emergency, is there someone who lives near you that we should contact?

Their Name: Relation:

Work#: Home#:

Medical History4. Do you have a personal physician? No Yes

Physician’s Name:

Phone #: Date of last visit:

CONTINUED ON BACK OF FORMI hereby authorize payment directly to the below name dentistof the group insurance benefits otherwise payable to me. SIGNED (Insured Person)

PAUDEN_111 (11/15)

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical / dental information above

with the parent / guardian & patient named herein.

Initials Date

Doctor’s Comments:

Medical History Update

1. Date Signature:

Billing Address:

2. Date Signature:

Billing Address:

Medical History (continued)

Your current physical health is: Good Fair Poor

Are you currently under the care of a physician? Yes No

Please explain

Are you taking any prescription / over-the-counter drugs? Yes No

Please list each one

For Women: Are you taking birth control pills? Yes No

Are you pregnant? Yes No Week#

Are you nursing? Yes No

4.Primary Dental Insurance

Why have you come to the dentist today?

Are you currently in pain? Yes No

Have you ever had a serious / difficult problem associated with any previous dental work? Yes No

Do you now or have you ever experienced pain or discomfort in your jaw joint (TMJ/TMD)? Yes No

Your current dental health is: Good Fair Poor

Do you like your smile? Yes No

Do your gums ever bleed? Yes No

How many times a week do you floss?

How many times a day do you brush?

Type of bristles? Hard Medium Soft

Dental History5.

Have you ever had any of the followingdiseases or medical problems?

Y N Heart Attack / Stroke Y N Tuberculosis (TB)Y N Cancer / Chemotherapy Y N Drug / Alcohol AbuseY N Heart Murmur Y N Venereal DiseaseY N Rheumatic Fever Y N Hemophilia/Abnormal BleedingY N HIV+ / AIDS Y N Ulcers / ColitisY N Heart Surgery / Pacemaker Y N Congenital Heart defectY N Shingles Y N Anemia/Radiation TreatmentY N Mitral Valve Prolapse Y N Asthma/ArthritisY N Kidney Problems Y N Difficulty BreathingY N Artificial Bones/Joints Y N Hospitalized for Any ReasonY N Sinus Problems Y N HepatitisY N High/Low Blood Pressure Y N Blood TransfusionY N Fever Blisters/Canker Sores Y N Emphysema/GlaucomaY N Severe/Frequent Headaches Y N Scleroderma/LupusY N Psychiatric Problems Y N FibromyalgiaY N Epilepsy/Seizures/Fainting Spells Y N Multiple SclerosisY N Hypoglycemia/Diabetes Y N Tobacco Use

Are you taking or have you ever taken any medication for Osteoporosis or cancer, either orally or by IV?

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following drugs or foods?Y N Penicillin Y N Codeine Y N NutsY N Aspirin Y N Latex Y N StrawberriesY N Erythromycin Y N Sulfa Y N AvacadoesY N Tetracycline Y N Other Y N KiwiY N Dental Anesthetics

Please List any other drugs that you are allergic to:

understand that the information that I have given today is

correct to the best of my knowledge. I also understand that this informa-

tion will be held in the strictest confidence and it is my responsibility to

inform this office of any changes in my medical status. I authorize the

dental staff to perform any necessary dental services with my informed

consent that I may need during diagnosis and treatment.

SIGNATURE DATE

I

Payment is due in full at the time of treatment unlessprior arrangements have been approved.

Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.

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Our office is committed to meeting or exceeding the standards ofinfection control mandated by OSHA, the CDC and the ADA