Gender:   Male  Female 

Status:   Minor  Single  Married  Divorced  Widowed  Separated 

Calling Preference:   Home  Work  Cell 

Who is responsible for the account?

In the event of an emergency, who should we contact?

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 other 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.

I Understand And Authorize:   Yes  No 

For your convenience, we offer the following methods of payment. Please check the option which you prefer. Payment in full at each appointment

Payment Type:   Cash  Personal Check  Credit Card - MC  Credit Card - Visa  I wish to discuss the dental office's policy 

Check the box if you have or have had any of the following

AIDS:   Yes  No 

Allergies(Seasonal):   Yes  No 

Anemia:   Yes  No 

Angina:   Yes  No 

Arthritis:   Yes  No 

Artificial Joints:   Yes  No 

Asthma:   Yes  No 

Cancer:   Yes  No 

Cardiac Pacemaker:   Yes  No 

Diabetes:   Yes  No 

Dizziness/fainting:   Yes  No 

Easily Winded:   Yes  No 

Eczema:   Yes  No 

Emphysema:   Yes  No 

Epilepsy/seizures:   Yes  No 

Excessive Bleeding:   Yes  No 

Frequently Tired:   Yes  No 

Glaucoma:   Yes  No 

Head Injuries:   Yes  No 

Heart Attack:   Yes  No 

Heart Bypass:   Yes  No 

Heart Disease:   Yes  No 

Heart Murmur:   Yes  No 

Hepatitis A:   Yes  No 

Hepatitis B:   Yes  No 

High Blood Pressure:   Yes  No 

Joint Replacement:   Yes  No 

Kidney Disease:   Yes  No 

Leukemia:   Yes  No 

Liver Disease:   Yes  No 

Low Blood Pressure:   Yes  No 

Mental Disorder:   Yes  No 

Mitral Valve Disorder:   Yes  No 

Radiation Therapy:   Yes  No 

Respiratory Problems:   Yes  No 

Recent Weight Loss:   Yes  No 

Rheumatic Fever:   Yes  No 

Sexually Transmitted:   Yes  No 

Sinus Problems:   Yes  No 

Stomach Problems:   Yes  No 

Stroke:   Yes  No 

Swollen Ankles:   Yes  No 

Thyroid Problems:   Yes  No 

Tuberculosis:   Yes  No 

Ulcers:   Yes  No 

No known conditions

Are you allergic to or have you had any reactions to the following:

Novacaine:   Yes  No 

Penicillin:   Yes  No 

Sulfa:   Yes  No 

Barbiturates:   Yes  No 

Sedative:   Yes  No 

Iodine:   Yes  No 

Aspirin:   Yes  No 

Metal- Nickel Mercury:   Yes  No 

Latex:   Yes  No 

Other:   Yes  No 

No known Allergies

No Medical History

Are You Currently Under Medical Treatment?:   Yes  No 

Have You Been Hospitalized For Any Surgical Operation Or Illness In The Last 5 Years?:   Yes  No 

Are you taking any medications including non-prescription medicine?(If you have a list we will copy it instead)

Are You On Blood Thinner?:   Yes  No 

Are You Able To Suspend Med For Dental Treatment?:   Yes  No 

Do You Use Controlled Substances?:   Yes  No 

Are You Pregnant?:   Yes  No 

Are You Nursing?:   Yes  No 

Are You Taking Birth Control:   Yes  No 

No Dental History

Do We Have Your X-rays From This Provider?:   Yes  No