R. MIKE MCBRIDE, D.D.S., P.A. JEREMY R. ROBBINS, D.D.S., P.A

R. MIKE MCBRIDE, D.D.S., P.A.JEREMY R. ROBBINS, D.D.S., P.A.

PATIENT INFORMATIONPatient Name:

Last First MI (Preferred Name)Referred By: Date:Gender (M/F): Marital Status: Birth Date: Social Security #:Address:

Street Apartment #

City State Zip Code Phone #’s: Home: Work: ext: Best Time to Call:

FAX: Cell: Other:

EMERGENCY INFORMATIONIN CASE OF EMERGENCY: PERSON TO CONTACT (friend or relative not living with you)Name: Address: Phone #:

SPOUSE OR RESPONSIBLE PARTY INFORMATIONName:

Last First MI (Preferred Name)Referred By: Date:Gender (M/F): Marital Status: Birth Date: Social Security #:Address:

Street Apartment #

City State Zip Code Phone #’s: Home: Work: ext: Best Time to Call:

FAX: Cell: Other:

EMPLOYMENT INFORMATION�e following is for: the patient the person responsible for paymentEmployer Name: Employer Phone:

Address:Street City State Zip Code

INSURANCE INFORMATIONPrimaryName of Insured:

Last First MIInsured’s Birth Date: ID #: Group #:

Insured’s Address:Street City State Zip Code

Insured’s Employer Name: Employer Phone:


Patient’s relationship to insured: Self Spouse Child Other

Insurance Plan Name and Address:

Name of Insured:Last First MI

Insured’s Birth Date: ID #: Group #:

Insured’s Address:Street City State Zip Code

Insured’s Employer Name: Employer Phone:


Patient’s relationship to insured: Self Spouse Child Other

Insurance Plan Name and Address:

Secondary


Patient Name:

Date:

This o�ce does not discriminate on thebasis of race, sex, sexual orientation,national orgin, age, or disability.This o�ce is in compliance with thelatest state and federal infection controlrequirements.This o�ce protects the privacy of allpatients.

Physicians Name: Phone #:

HEALTH HISTORY

YES NO

Are you under any medical treatment now?...............................................................

If yes, please explain:

Are you taking any daily medication?Vitamins, Minerals ,Herbal Supplements, OTC...............................................................

If yes, please list:

Are you allergic to penicillin, amoxicillin, sulfa, local anesthetics, othermedications, latex, vinyl, any metal or reaction to jewelry?........................................


Do you have a history of:

Heart disease or stroke?.........................................................................................................High or low blood pressure?................................................................................................Circulatory problems?............................................................................................................Rheumatic fever, heart murmur, prolapsed valve?........................................................Any prosthesis - hips, valves, shunts, pins, plates?.........................................................Diabetes, hypoglycemia, or kidney disease?..................................................................Anemia or bleeding problems?..........................................................................................Hepatitis, jaundice or liver disease?..................................................................................AIDS or HIV infection?..........................................................................................................Nervous problems?................................................................................................................Ulcers or herpetic lesions (fever blisters)?......................................................................Chemical dependency?........................................................................................................Tuberculosis or lung disease?.............................................................................................

YES NO

Do you have a dental problem now?............................................................................

If yes, please explain:

Do you have or have been treated for TMJ problems?...............................................


Arthritis or rheumatism?........................................................................................................Environmental allergies or sinus trouble?.........................................................................�yroid or endocrine disorder?..........................................................................................Radiation or chemotherapy?................................................................................................Fainting spells or seizures?.....................................................................................................Breathing problems, asthma, or emphysema?.................................................................Do you smoke or chew tabacco?.........................................................................................

Other?

YES NO

DENTAL HISTORY

Do you clench or grind your teeth?...................................................................................Do you wear a splint or mouthguard?...............................................................................Are any of your teeth sensitive to hot, cold, or sweets?..............................................Have you ever had a root canal?.........................................................................................Have you ever had orthodontic treatment?....................................................................Do you frequently drink soda pop?...................................................................................Do you regularly suck or chew on candies of any kind?...............................................Are you happy with the appearance of your teeth?.....................................................Do you have any speci�c questions you would like to discuss?.................................

When was your last dental visit and for what reason did you seek dental care?

How o�en do you brush your teeth each day?1 -2 times 2 - 3 times 3+ times

How o�en do you �oss? Daily Weekly InfrequentlyHow o�en and with what do you rinse?

Patient/Parent Signature

Date: Date:

Dentist’s Signature


ACKNOWLEDGMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

*You May Refuse to SIgn This Acknowledgment*

I, have received a copy of this o�ce’s Notice of Privacy Practices.

Please Print Name

Signature

Date

For O�ce Use Only

We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgmentcould not be obtained because:

Individual refused to sign Communication barriers prohibited obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment Other (Please Specify)

© 2002 American Dental Association, All Rights Reserved.

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This form iseducational only, does not constitute legal advice, and covers only federal, not state law (August 14, 2002).

Documents

R. MIKE MCBRIDE, D.D.S., P.A. JEREMY R. ROBBINS, D.D.S., P.A