PLEASE FILL OUT THE FORM







Gender:
MaleFemale
Are You?
SingleMarriedWidowedMinor




IN CASE OF EMERGENCY, CONTACT




HOME PHONE

WORK PHONE

CELL PHONE


REASON FOR VISIT


DENTAL INSURANCE(for re-imbursement)







YOU USUALLY SEE A DENTIST:

LAST DENTAL VISIT:

IF YOU COULD CHANGE ANYTHING ABOUT YOUR TEETH, WHAT WOULD IT BE?

DO YOU HAVE OR EVER HAD

VENEREAL DISEASEHEPATITIS OR LIVER DISORDERARTIFICIAL HEART VALVEARTIFICIAL JOINTS/HIPSDIABETESEPILEPSYARTHRITISAIDSCANCERASTHMAGLAUCOMATUBERCULOSISPSYCHIATRIC CAREABNORMAL BLEEDINGBAD BREATHFOOD IMPACTIONSWELLING IN MOUTHUNPLEASANT TASTEAVOID BRUSHING AREAS OF YOUR MOUTHCLENCHING OR GRINDING OF TEETHCOMPLICATIONS FROM EXTRACTIONSFEVER BLISTERS OR COLD SORESHEART TROUBLEPHEUMATIC FEVERHIGH BLOOD PRESSUREHEART MURMURKIDNEY DISORDER

WOMEN:
PREGNANTNURSINGON BIRTH CONTROL







ARE YOU ALLERGIC TO ANYTHING?

ARE YOU ALLERGIC TO ANYTHING?

DO YOU WISH TO SPEAK TO THE DOCTOR PRIVATELY ABOUT ANY PROBLEM?

NAME OF YOUR PHYSICIAN?

PHYSICIANS NUMBER:




I understand and agree that I am financially responsible for all charges, whether or not paid by insurance. I also
agree that I am responsible if my account is placed for collections, which includes but is not limited to interest
charges and attorney fees. I certify that the information that I have provided on both sides of this form is true and
correct to the best of my knowledge. I agree to inform the doctor of any changes in my health status or the above
information.

PLEASE SIGN IN BOX BELOW:



DATE