First name:

First name:
Last name:
************************************************************* Do you have a secondary carrier? If yes: Employer: ************************************************************* MEDICAL HISTORY (please circle the appropriate answer)
Have you had a medical examination in the last year? Have you had a serious illness or are you under the care of a physician now? Do you use medication regularly? (please list all medications that you take) Are you allergic to or have you experienced any unusual reactions to any of the following? (please
circle any that apply)
Have you ever had an injury, surgery or x-ray therapy on your face or jaw? Is there any history of family disease? (please indicate) 11. Have you had or do you currently have any of the following? (please circle all that apply)
12. Have you had or are you at risk for cancer? 13. Do you have a tendency to faint or suffer from dizzy spells? 14. Do you suffer from frequent/severe headaches? 15. Do you have a prosthetic implant? (i.e. heart pacemaker/hip prosthesis) 17. Are you feeling any pain or discomfort at this time? 18. Would you like to speak to the Dentist privately? 19. FOR WOMEN ONLY: Are you or could you be pregnant? (If yes, which month)

1. Do you have any dental problems at present? (If yes, please provide a brief history of the condition) Previous dentist (for requesting x-rays) 3. Have you had teeth extracted due to accident, decay or gum disease? (please circle any that apply) 4. Have you had crowns, fixed bridges, partial or full dentures? (please circle any that apply) 5. Have you had root canal treatment, orthodontic or periodontal (gum) treatment? (please circle any that apply) 6. Do you habitually: clench/grind your teeth, bite your nails or suck your thumb? (please circle any that apply) 7. Do you have any disease, condition or problem, not listed previously, that you think the Doctor should know about?
I, the undersigned, understand that the information contained in this document is important to my treatment and I certify that all of the information is correct and I have not knowingly omitted anything. I authorize the dental office to perform diagnostic procedures, as may be required, to determine and/or perform necessary treatment. I understand that payment is expected, in full, for services rendered at the appointment unless previous financial arrangements have been made. Signature of Patient (Signature of parent or guardian in case of a minor) ** Insurance: the particular plan which you have is a contract between yourself and the company providing benefits.
As a service to our clients, we are willing to bill your plan directly. However, you must understand that many plans
exist and all plans do not provide the same benefits. It is your responsibility to settle any balance left unpaid by your
insurance company. If you have any questions or concerns please let us know.



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