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Patient Information
Patient Name ___________________________________ If a child, parent's name ___________________________ Marital Status of Patient: (please circle) Married, Divorced, Single. Separated, Widowed Patient's Date of Birth________________ Age _________ Patient's SS# ___________________________________ Address / Street _________________________________ City _____________________ State_____ Zip_________ Home Phone # __________________________________ Cel Phone # ____________________________________ Business Phone # _______________________________ Email _________________________________________ Employer ______________________________________ Whom may we thank for referring you to our office? ______________________________________________ In case of an emergency, who should be notified? Name _________________________________________ Relationship to patient ____________________________ Phone number __________________________________ Dental Insurance Primary Dental Insurance Insurance Co Name ______________________________ Insurance Address _______________________________ _______________________________________________ Insurance Phone # _______________________________ Name of Insured _________________________________ Insured's Birthday ________________________________ Insured's Social Security # _________________________ Insured's ID # ___________________________________ Group Number __________________________________ Insured's Employer _______________________________ Secondary Dental Insurance Insurance Co Name ______________________________ Insurance Address _______________________________ Insurance Phone # _______________________________ Name of Insured ____________________DOB_________ Insured's Social Security # _________________________ |
Dental Information
Have you ever been told that you meed an antibiotic before dental treatment? Y / N If so, for what? ____________________________________ When was your last visit? ___________________________ ________________________________________________ Are you having dental discomfort at this time? ----- Y / N Do you have pain in your jaw or near your ears? -- Y / N Do you have unhealed injuries or inflamed areas in or around your mouth? ------------------------------------------------ Y / N Any reaction or allergic symptoms to Novocain, local or general anesthetic? -------------------------------------------------- Y / N Any difficult extractions in the past? ------------------ Y / N Any prolonged bleeding following extraction in the past? ----------------------------------------------------- Y / N Do your gums bleed? ------------------------------------- Y / N Do you have a bad taste in your mouth or mouth odor? ------------------------------------------------- Y / N Have you ever had Periodontal Treatment? --------- Y / N Do you habitually clench or grind your teeth during the day or night? ---------------------------------------------------------- Y / N Are any parts of your mouth sensitive to Hot, Cold or Sweets? --------------------------------------------------- Y / N Do you have dental implants? -------------------------- Y / N Is there anything about the appearance of your teeth that you would like to change? ------------------------------------- Y / N If so, what? ______________________________________ Medical Care Do you have a personal physician? ------------------- Y / N Physician's name _________________________________ Are you presently under your physician's care? ---- Y / N If so, for what? ___________________________________ Are you taking any medications? ----------------------- Y / N Please list: ______________________________________ _______________________________________________ _______________________________________________ Vertical Divider
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