WELCOME TO OUR OFFICE
Today’s Date: _____________________
About You:
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Patient Name: _______________________________________________________ Last First MI Birthdate: _____/_____/_____ Age:_______ SS# _______-________-___________ Mailing Address: ____________________________________________________________________________ __________________________________________________________________ City State Zip Home Phone: __________________ Cell: ___________________Work Phone: __________________ Referred by:________________________________ Dentist: ________________________________ Employer: __________________________________Occupation: _____________________________ Employer Address: __________________________________________________________________ Status: q Minor q Single q Married q Divorced q Separated q Widowed |
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Company Name: __________________________________________ Phone: ________________________
Address: ____________________________________________ Group: __________________________
____________________________________________ Insured’s SS# _______-______-_________
Insured’s Name: ______________________________________ Relationship:________________________
Insured’s Employer:____________________________________ Date of Birth:______/_______/______
Company Name: __________________________________________ Phone: ________________________
Address: ____________________________________________ Group: __________________________
____________________________________________ Insured’s SS# _______-______-_________
Insured’s Name: ______________________________________ Relationship:________________________
Insured’s Employer:____________________________________ Date of Birth:______/_______/______ |
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Name: ______________________________Home Phone: _______________Work Phone: _________________
Relation: _____________________ Medical Doctor: _______________________ MD Phone: _____________ |
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Please list any medications currently taken:
__________________________________________________________________________________________
___________________________________________________________________________________________
Do you have or ever had any of the following diseases or medical conditions? |
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q Heart Attack/Stroke |
q Kidney Problems |
q Cancer/Tumors |
q Chemotherapy |
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q Heart Surg./Pacemaker q Heart Murmur q Rheumatic Fever q Mitral Valve Prolapse q Artificial Valves q Heart Disease q Congenital Heart Defect q Chest Pains q Scarlet Fever |
q Liver Problems q Respiratory Problems q Sinus Problems q Stomach Problems/Ulcers q Psychiatric Problems q Venereal Disease q Alcohol/Drug Abuse q Tuberculosis TB q Jaw problems (TMJ) |
q Shingles q Hepatitis q HIV+/AIDS/ARC q Arthritis/Rheumatism q Artificial Bones/Joints q Emphysema q Fainting/seizures/Epilepsy q Severe/Frequent headaches q Frequent neck pain |
q Asthma q Difficulty Breathing q Diabetes/Hypoglycemia q Leukemia q Anemia q High/Low Blood Pressure q Bleeding Problems q Glaucoma q Back Problems |
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Please list any other medical condition(s) you have or ever had; ______________________________________
___________________________________________________________________________________________ |
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Please list any known allergies:
____________________________________________________________________________________
q For Women: Are you pregnant? q Yes q No Are you taking Birth Control Pills? q Yes q No
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I
understand the above information and guarantee this form was completed correctly
to the best of my knowledge and understand it is my responsibility to
inform this office of any changes to the information I have provided.
Signature: _______________________________________________ Date: ________________
Patient/Guardian
(Office Use)
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UPDATE Date:______________ Comments:
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UPDATE Date:____________ Comments: |