MEDICAL HISTORY FULL NAME D.O.B. SEX

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MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY RADIATION TREATMENT ALZHEIMER S OR OTHER DEMENTIA* FAINTING OR DIZZINESS RESPIRATORY DISEASE ANEMIA GLAUCOMA RHEUMATIC FEVER ARTHRITIS, RHEUMATISM HEADACHES SCARLET FEVER ARTIFICIAL HEART VALVES HEART MURMUR SEXUALLY TRANSMITTED DISEASE ARTIFICIAL JOINTS HEART PROBLEMS SHORTNESS OF BREATH ASTHMA HEPATITIS TYPE SINUS TROUBLE BACK PROBLEMS HERPES SKIN RASH BLEEDING, DELAYED CLOTTING HIGH BLOOD PRESSURE SPECIAL DIET BLOOD DISEASE JAUNDICE STROKE CANCER JAW PAIN SWOLLEN FEET OR ANKLES CHEMICAL DEPENDENCY KIDNEY DISEASE SWOLLEN NECK GLANDS CHEMOTHERAPY LIVER DISEASE THYROID PROBLEMS CIRCULATORY PROBLEMS LOW BLOOD PRESSURE TONSILITIS CONGENITAL HEART LESIONS MITRAL VALVE PROLAPSE TUBERCULOSIS CORTISONE TREATMENTS NERVOUS PROBLEMS TUMOR OR GROWTH ON HEAD OR COUGH, PERSISTENT OR BLOODY OSTEOPOROSIS NECK DIABETES PACEMAKER ULCER EMPHYSEMA PSYCHIATRIC CARE* WEIGHT LOSS, UNEXPLAINED * IF THERE IS ANOTHER INDIVIDUAL THAT SHOULD BE CONSULTED REGARDING TREATMENT DECISIONS, PLEASE PROVIDE THEIR NAME AND CONTACT INFO DO YOU HAVE ANY OTHER CONDITIONS NOT LISTED ABOVE? YES NO IF YES, PLEASE EXPLAIN HAVE YOU HAD SURGERY OR BEEN HOSPITALIZED IN THE PAST YEAR? YES NO IF YES, PLEASE EXPLAIN HAVE YOU EVER BEEN INSTRUCTED TO TAKE ANTIBIOTICS BEFORE A DENTAL APPOINTMENT? YES NO IF YES, PLEASE TELL US WHICH ANTIBIOTIC AND FOR WHAT CONDITION WOMEN ARE YOU PREGNANT? YES NO DUE ARE YOU NURSING? YES NO CONTINUED ON BACK

ALLERGIES ASPIRIN CODEINE LATEX PENICILLIN BARBITUATES IODINE LOCAL ANESTHETIC SULFA OTHERS MEDICATIONS PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS YOU ARE CURRENTLY TAKING: BLOOD PRESSURE (mmhg) TO BE TAKEN AT APPOINTMENT PULSE (BPM) The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of t his form. Reservation Policy: Each appointment is a reservation with one of our Doctors or Hygienists and we strive to be punctual because we value our patients time. We ask for a minimum of 24 hours notice to cancel or reschedule any reservations and to avoid a Missed Reservation Fee. For appointments over 2 hours long or scheduled outside of our normal business hours, we request a 25% non-refundable deposit to secure your reservation. PATIENT S SIGNATURE DENTIST S SIGNATURE

WELCOME FULL NAME D.O.B. SEX PREFERRED NAME SSN ADDRESS CITY, STATE ZIP HOME PHONE BUSINESS/CELL PHONE MARITAL STATUS SPOUSE S NAME OCCUPATION REFERRED BY EMAIL ADDRESS EMERGENCY CONTACT RELATIONSHIP PHONE HOW WOULD YOU LIKE TO BE REMINDED OF YOUR APPOINTMENT? PHONE CALL TEXT MESSAGE EMAIL REASON FOR TODAY S VISIT DENTAL HISTORY FORMER DENTIST OF LAST VISIT CITY, STATE OF LAST X-RAYS PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: BAD BREATH FOOD COLLECTION BETWEEN TEETH ORTHODONTIC TREATMENT BLEEDING GUMS FOREIGN OBJECTS E.G., PIERCINGS PAIN AROUND EAR BLISTERS ON LIPS OR MOUTH GRINDING TEETH PERIODONTAL TREATMENT BURNING SENSATION ON TONGUE GUMS SWOLLEN OR TENDER SENSITIVITY TO COLD CHEW ON ONE SIDE OF MOUTH JAW PAIN OR TIREDNESS SENSITIVITY TO HEAT CIGARETTE, PIPE, OR CIGAR SMOKING LIP OR CHEEK BITING SENSITIVITY TO SWEETS CLICKING OR POPPING JAW LOOSE TEETH OR BROKEN FILLINGS SENSITIVITY WHEN BITING DRY MOUTH MOUTH BREATHING SORES OR GROWTHS FINGERNAIL BITING MOUTH PAIN, BRUSHING HOW OFTEN DO YOU BRUSH? HOW OFTEN DO YOU FLOSS? PATIENT AGREEMENT 1 I understand that all outstanding balances are due at the time services are rendered. If payment is not received within 30 days, or if I designate prior, my credit card on file may be charged for any 2 outstanding balances due. Reservation Policy: Each appointment is a reservation with one of our Doctors or Hygienists and we strive to be punctual because we value our patients time. We ask for a minimum of 24 hours notice to cancel or reschedule any reservations 3 and to avoid a Missed Reservation Fee. For appointments over 2 hours long or scheduled outside of our normal business hours, we request a 25% non-refundable deposit to secure your reservation. PLEASE RETURN THIS FORM WITH: 1) A FORM OF GOVERNMENT-ISSUED ID, 2) CREDIT CARD, AND 3) INSURANCE CARD PATIENT S SIGNATURE DENTIST S SIGNATURE

FULL NAME PREFERRED NAME PERSONALIZE YOUR VISIT (OPTIONAL) D.O.B. PLEASE SELECT FROM THE FOLLOWING COMPLIMENTARY OPTIONS BLANKET GLUTEN- FREE PRODUCTS PILLOW BOTTLE OF WATER LIP BALM WARM TOWELETTE PREFERRED POLISHING PASTE FLAVOR GLUTEN- FREE PLAIN GLUTEN- FREE MINT BUBBLE GUM CHERRY SURPRISE ME! ENTERTAINMENT TV INTERNET RADIO EARPHONES EARPLUGS NONE PREFERRED APPOINTMENT TIME EARLY MORNING LATE MORNING EARLY AFTERNOON LATE AFTERNOON FLEXIBLE PREFERRED APPOINTMENT DAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

PARKING Underground valet or street parking is available. Thick lines on the above map indicate streets with free 2-hour parking. Subject to change without notice.

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