New Patient Medical History

Are you under a physician’s care now?

Yes No

If yes, Please Explain

Have you ever been hospitalized or had a major operation?

Yes No

If yes, Please Explain

Have you ever had a serious head or neck injury?

Yes No

If yes, Please Explain

Are you taking any medications, pills, or drugs?

Yes No

If yes, Please Explain

Do you take, or have taken, Phen-Fen or Redux?

Yes No

If yes, Please Explain

Have you ever taken Fosmax, Boniva, Actonel or any other medication containing bisphosphonates?

Yes No

If yes, Please Explain

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

If yes, Explain

Women: Are you……

Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?

If other, Please specify

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Sulfa Drugs

Local Anesthetics

Other

Have you had any serious illness not listed above?

Authorization & Release (Please read carefully)

I certify that I have read and answered accurately the questions to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis, x-rays, photographs, and the records of any treatment or examination rendered to me or my child to third party payors and/or health practitioners. I authorize and request my insurance company to directly to Dr. Richard Mark insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my behalf or the behalf of my dependent. I understand that if my account is not paid in full within 45 days of billing, a late payment fee of $15 per month will be charged to my account. If no payment had been received or financial arrangement made on my balance after 90 days, my account will be referred for collection. If referred for collection, I understand that I will be responsible for the balance as well as any fees involved in the collection process.

I understand it is my responsibility to provide current identification verification and insurance card at check in.

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.

Signature / Name

Date

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