Thank you for selecting our dental healthcare team!We will strive to provide you with the best possible dental

care. To help us meet all your dental healthcare needs, pleasefill out thisform completely in ink. ifyou have any questionsor need assistance, please ask us - we will be happy to help.

Patient # _

n· I .£ . sS#/SINrtlttent nJonnatton (CONFIDENTIAL) Date _Name Birthdate Home Phone_~..,-- _

State/ Zip)Address City Prov. P C _Email Cell Phone _

Check Appropriate Box: D Minor D Single D Married D Divorced D Widowed D Separat£d 11::,tate/ Fu Partif Student, Name of School/College City Prov. D Time D Time

Patient or Parent/Guardian's Employer Work Phone_-=-:- _State! Zip)Business Address City Prov. P C. _

Spouse or Parent/Guardian's Name Employer Work Phone _Whom may we thank for referringyou?Person to contact in case of emergenry Phone _

Responsible Party l' h'Re atwns lpName of Person Responsiblefor this Account to Patient _Address Home Phone _Email Cell Phone _Driver's License# Birthdate Financial Institution _Employer Work Phone SS#/SIN _

Is this person currently a patient in our office? D Its D NoFor your convenience, we offer thefollowing methods of payment. Please check the optionyou prljer:Payment in full at each appOintment.D Cash D Personal Check Credit Card D VISA D MasterCard D I wish to discuss the office'spayment poliry.

Insurance Infonnation DDiscover DAMEX'J' Relationship

Name of Insured to Patient _

Birthdate SS#/SIN Date Employed -----Name of Employer Union or Local# Work Phone _~. -,-- _

State/ ZmLAddress of Employer City Prov. Pt...,. _Insurance Company Group# Poliry/ID#_----",,.,--.-,- _

State/ Zip,/Ins. Co. Address City PrOy pc. _How much isyour deductible? How much have you used? Max. annual benefit _

DO YOU HAVEANY ADDITIONAL INSURANCE? DYes DNo IF YES, COMPLETE THE FOLLOWING:

RelationshipName of Insured - to Patient _

Birthdate SS#/SIN Date Employed -----Name of Employer Union or Local# Work Phone _."..--.--,--- _

State/ ZlVjAddress of Employer City PrOy Pt...,. _Insurance Company Group# Po Iiry/ID#_--",,.,-. -,--- _Ins. Co. Address City *~t:/ ~Pt. _How much is your deductible? How much have you used? Max. annual benefit _

Over Please

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Patient Medical HistoryPhysician Office Phone Date of Last Exam _

Yes1.Are you under medical treatment now;> 02. Have you ever been hospitalized for any

surgical operation or serious illness within the last 5 years;> 0If yes, please explain _

Nooo

Yes9. Are you wearing contact lenses? 0

10.Areyou allergic to or haveyouhad any reactions to thefollowing?Local Anesthetics (e.g. Novocain) 0Penicillin or any other Antibiotics... 0~~~~i~~f:s ::::.:::::::.::::::::.::::::::: ::::::::: ::::::::::.. 8Sedatives.. 0Iodine.......... 0Aspirin... . 0Any Metals (e.g. nickel, mercury, etc.).............. 0Latex Rubber 0Other (please list)

11. Doyou havea persistentcoughor throat clearingnotassociatedwith a known iUness(lastingmore than 3 weeks)? ..

12. Women Only:a) Are you pregnant or think you may be pregnant? ....b) Are you nursing? .c) Are you taking oral contraceptives? ..

Yes Noo 0o 0o 0o 0o 0o 0o 0o 0o 0o 0o 0o 0o 0o 0

3. Are you taking any medication(s)including non-prescription medicine? 0If yes, what medication(s) are you taking? _

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..0 o4. Have you ever taken Fen-Phen/Redux? .5. Haveyou ever taken Fosamax, Boniva, Actonel or any cancer

medications containing bisphosphonates;>.. 06. Do you use tobacco? 07. Do you use controlled substances? 0

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8. Do you have or have you had any of the following;>Yes No

High Blood Pressure.. 0 0Heart Attack ..... 0 0Rheumatic Fever 0 0Swollen Ankles..................... 0 0Fainting / SeiZures....... 0 0Asthma....... 0 0Low Blood Pressure 0 0Epilepsy / Convulsions 0 0Leukemia 0 0Diabetes...................... 0 0Kidney Diseases 0 0AIDS or HIV Infection. 0 0Thyroid Problem... 0 0Acid Reflux .. . 0 0

Patient Dental HistoryName of Previous Dentist and Location Date of Last Exam -----------l

Yes No YesDo your gums bleed while brushing or flOSSing? 0 0 8. Do you have frequent headaches? 0Are your teeth sensitive to hot or cold liquidsifoods?.. 0 0 9. Do you clench or grind your teeth? 0Are your teeth sensitive to sweet or sour liquidsifoods ( .... ..... 0 0 10. Do you bite your lips or cheeks frequently? .. 0Do you feel pain to any of your teeth ( .. 0 0 11. Have you ever had any difficult extractionsDo you have any sores or lumps in or near your mouth?.. 0 0 in the past? . 0Have you had any head, neck or Jaw inJuries(.. 0 0 12. Have you ever had any prolonged bleedingHave you ever experienced any of the following following extractions 7.. 0

problems in your jaw? 13. Have you had any orthodontic treatment;> 0Clicking.. . 0 0 14. Do you wear dentures or partials?....... 0Pain VOint, ear, side of face) 0 0 If yes, date of placement -:- _Difficulty in opemng or closing 0 0 15. Have you ever received oral hygiene instructionsDifficulty in chewing.. 0 0 regarding the care of your teeth and gums;>.. 0

Authorization and Release 16. Doyou like your smile? 0

Heart Disease .Cardiac PacemakerHeart Murmur .Angina .Frequently Tired ..Anemia .EmphysemaCancer ...Arthritis ..Joint Replacement or Implant ..Hepatitis / Jaundice ..Sexually Transmitted DiseaseStomach Troubles / Ulcers ..Osteoporosis..

Chest Pains ..Easily Winded.Stroke.Hay Fever / Allergies .Tuberculosis ..Radiation Therapy .GlaucomaRecent Weight Loss .Liver DiseaseHeart TroubleRespiratory ProblemsMitral Valve Prolapse ....Other _

I certify 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 dangerous to my health. I authorize the dentist to release any injormation including thediagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payorsamI/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefitsotherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsiblefor payment of all services rendered on my behalf or my dependents.

xSignature of patient (or parent/guardian if minor) Date

Doctor's Comments _

Signature Date

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