Registration and History

1

Patient Information

Sex
2

Dental Insurance

Is patient covered by additional insurance?

Assignment and release

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

3

Phone Numbers

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household)

4

Dental History

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Bad Breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivty to sweets
Sensitivity when biting
Sores or growths in your mouth
5

Health History

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
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).

Select "yes" or "no" to indicate if you had any of the following:

AIDS/HIV
Anemia
Arthritis, Rheumatism
Artifical heart valves
Artifical joints
Asthma
Back problems
Bleeding abnormally, with extractions or surgery
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Congential heart lesions
Cortisone treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart murmur
Heart problems
Hepatits type
Herpes
High blood pressure
Jaundice
Jaw pain
Kidney disease
Liver disease
Low blood pressure
Mitral valve prolapse
Nervous problems
Pacemaker
Psychiatric care
Radiation treatment
Respiratory disease
Rheumatic fever
Scarlet fever
Shortness of breath
Sinus trouble
Skin rash
Special diet
Stroke
Swollen feet or ankles
Swollen neck glands
Thyroid problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal disease
Weight loss, unexplained
Do you wear contact lenses?

Women:

Are you pregnant?
Taking birth control pills?
Are you nursing?

Medications

Allergies

6

Updates (to be filled in at future appointment)

Has there been any change in your health since your last dental appointment?
Has there been any change in your health since your last dental appointment?