Patient Information

Date

Referred By

Patient Name

Date of Birth

If minor, name of Parent/Legal Guardian

Home Address

Phone

City

State

Zip Code

Patient Occupation

Employer

Work Address

Phone

City

State

Zip Code

Name of Spouse (if married)

Spouse Occupation

Employer

Spouse Work Address

Phone

City

State

Zip Code

PERSON RESPONSIBLE FOR ACCOUNT

Relationship to Patient

Address (if different from patient)

Phone

City

State

Zip Code

DENTAL INSURANCE CARRIER

Name of Primary Subscriber

Date of Birth

Subscriber ID #

Relationship to Patient

Policy Group #

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Health Questions

Do you normally take antibiotics before dental appointments?

Yes No

Have you ever been a patient in a hospital in the past 2 years?

Yes No

Have you ever been under the care of a physician during the past year?

Yes No

Physician Name

Phone

Are you currently taking any medications?

Yes No

Please list (including aspirin or birth control)

Are you subject to prolonged bleeding?

Yes No

Women: are you nursing or pregnant?

Yes No

How many months?

Hip or other joint replacement?

Yes No

When?

Do you haveTMJ (jaw) problems?

Yes No

PLEASE CHECK ANY ILLNESS YOU HAVE HAD OR HAVE PRESENTLY:

Heart Attack: When?

Transfusion: When?

Cancer: Type of Cancer?

CHECK ITEMS TO WHICH YOU HAVE REACTIONS OR ALLERGIES:

Penicillin

Clindamycin

Aspirin

Ibuprofen

Valium

Codeine

Local Anesthetic

Latex

Nickel

List Others

IS THERE ANY OTHER INFORMATION REGARDING YOUR HEALTH OR PAST EXPERIENCES WITH DENTAL TREATMENT/ROOT CANALS THAT WE SHOULD KNOW?

I hereby certify that the above information is correct to the best of my knowledge.

Today's Date

Signature of Patient, Parent or Guardian

Doctor Signature

Date

Your information will be encrypted.