W E L ( 0 M E PATI ENT IN FORMATION Date ______________________________________________

SS/HIC/Patient 10 # _______________ _

Patient______________________________________________

Address___________________________________________

City _ ___________________

State ________ ____ Zip _ ________

E-mail _____________________________________________

Sex D M D F Age _____ ___

Birthdate____________________________ _

D Married DWidowed D Single DMinor

D Separated D Divorced D Partnered for ___ years

Occupation __________________________________________

Patient Employer/School _______________________________

Employer/School Address

Employer/School Phone ( __) ______________

Spouse's Name _______________________________________

Birthdate ___________________________________________

SS# _______________________

Spouse's Employer ___________________________________ _

Whom may we thank for referring you? ______________________

DENTAL INSVRAN(E Who is responsible for this account? _________________________

Relationship to Patient _________________________________

Insurance Co. ________________________________________

Group #

Is patient covered by additional insurance? DYes D No

Subscriber's Name _______________________________________

Birthdate___________________ SS# _______________

Relationship to Patient _ _________________________________

I nsurance Co. ________________________________________

Group # ____________________________________________

ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with

_______---,-,--__-,-,-______ -:-____ -,,-...,-_____ and assign directly to Name of Insurance Company(ies)

Dr. all insurance benefits, if any, otherwise payable to me for services rendered . I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date Signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative

Date Relationship to Patient

PHONE NVMBERS Home ( ___ ) __________ _ Work ( ___)_ ____ ___ Ext Cell Phone ( _ __) _______

Spouse'sWork ( ___) Best time and place to reach you _____________________________________________

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name ___________________________________________________ Relationship ________________________________________

Home Phone ( ____) _ ___________________ Work Phone ( ___)____________ ___________

DENTAL HISTORY Reason for today's visit _________________

Former Dentist ________________________

City/State________________

Date of last dental visit __________________ _

Date of last dental X-rays ______________ __

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Bad breath DYes DNa

Bleeding gums DYes

Burning sensation on tongue

Chew on one side of mouth

Cigarette, pipe, or Cigar smoking

Clicking or popping jaw

Dry mouth

Fingernail biting

Food collection between the teeth

Foreign objects

Grinding teeth

Gums swollen or tender

Jaw pain or tiredness

Lip or cheek biting

DYes

DYes

DYes

DYes

D Yes

DYes

DYes

DYes

DYes

DYes

DYes

DNo

DNa

DNo

D Na

DNa

DNo

DNo

D Na

DNo

DNa

D Na

Mouth breathing DYes DNa

Mouth pain, brushing DYes DNo

Orthodontic treatment D Yes D No

Pain around ear DYes D No

Periodontal treatment DYes DNo

Sensitivity to cold DYes DNa

Sensitivity to heat DYes DNa

Sensitivity to sweets DYes DNa

Sensitivity when biting DYes D Na

Sores or growths in your mouth DYes D Na

How often do you floss?

___ _

____ _

_____________________________________________ _

HEALTH HI STORY Physician's Name _______________ ________________ Date of last visit._ _ ________

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine) . 0 Yes 0 No

Place a mark on "yes" or "no" to indicate if you have had any of the following : AIDS/HIV DYes DNo Epilepsy DYes DNo Respiratory Disease DYes

Anemia DYes DNo Fainting or dizziness DYes DNo Rheumatic Fever DYes

Arthritis, Rheumatism DYes DNo Glaucoma DYes DNo Scarlet Fever DYes D No

Artificial Heart Valves DYes DNo Headaches DYes D No Shortness of Breath DYes D No

Artificial Joints DYes DNo Heart Murmur DYes DNo Sinus Trouble DYes DNo

Asthma DYes DNo Heart Problems DYes DNo Skin Rash DYes o No

Back Problems DYes DNo Hepatitis Type DYes DNo Special Diet DYes DNo

Bleeding abnormally, with DYes DNo Herpes DYes DNo Stroke DYes D No extractions or surgery High Blood Pressure DYes DNo Swollen Feet or Ankles DYes DNo

Blood Disease DYes DNo Jaundice DYes DNo Swollen Neck Glands DYes D No Cancer DYes D No Jaw Pain DYes D No Thyroid Problems D Yes DNo Chemical Dependency DYes DNo Kidney Disease DYes D No Tonsillitis DYes DNo Chemotherapy DYes D No Liver Disease DYes D No Tuberculosis D Yes DNo Circulatory Problems DYes DNo Low Blood Pressure DYes D No Tumor or growth on head or DYes o No Congenital Heart Lesions DYes DNo neckMitral Valve Prolapse DYes D No Cortisone Treatments DYes D No Ulcer D Yes DNoNervous Problems D Yes O No Cough, persistent or bloody DYes D No Venereal Disease DYes DNoPacemaker DYes o No Diabetes DYes D No Weight Loss, unexplained DYes DNoPsychiatric Care DYes o No Emphysema DYes DNo Radiation Treatment D Yes o No

Do you wear contact lenses? DYes o No

Women:

Are you pregnant? 0 Yes DNo Due date Are you nursing? 0 Yes 0 No

Taking birth control pills? 0 Yes DNo

MEDl(ATIONS List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name _ ____________ ______

Phone(_ __) _ _ _________ ______

ALLE RC I ES o Aspirin o Local Anesthetic

o Barbiturates (Sleeping pills) o Penicillin

o Codeine o Sulfa

o Iodine o Other _______

o Latex

v r DATES (To b~ filled In at future appointments)

Has there been any change in your health since your last dental appointment? 0 Yes 0 No

For what conditions? _ _ ____________________________________________

Are you taking any new medications? _ _____ If so, what? _ ______________________ ______

Patient's Signature ___ _______________ _ _______________

Doctor's Signature __________________________________

Date_____

Date_____

_

Has there been any change in your health since your last dental appointment? 0 Yes

For what conditions?

0 No

Are you taking any new medications? ______ If so, what? _ _ _ _ _________________________

Patient's Signature __________________________________ Date'__________

Doctor's Signature _________________ _____ _ _ _ _____ ____ Date,__________