Dental History

Select Location

Reason For Today's Visit

Date Of Last Dental Care

Former Dentist

Date Of Last Dental X-Rays

Address

Check if you have had problems with any of the following

How Often Do You Floss?

How Often Do You Brush?

Medical History

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)?

Yes

Have you had any serious illness or operations?

Yes

If Yes, Describe

Have you ever had a blood transfusion?

Yes

If Yes, Give Approximate Dates

(Women)Are You Pregnant?

Yes

Nursing?

Yes

Taking Birth Control Pills?

Yes

Check if you have or have had any of the following

List medications you are currently taking and the correlating diagnosis

Allergies

Authorization And Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance coverage with Name of insurance Company(ies) and assign directly to 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 dentist 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 payable for related services. This consent will end when the current treatment plan is completed or one year for the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date

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

Relationship to Patient

Patient Name Validation

Payment is due in full at time of treatment unless prior arrangements have been approved.