Form

*The fields must be filled

Patient Information

Mr.

Mrs.

Ms.

Dr.

*First Name

*Last Name

Gender

Male

Female

*Birthday

*Email

*Street

*City

*State

*Zip

*Home Phone

*Cell

Are you a new patient?

Yes

*Your Primary Dentist

Your Primary Doctor

Referred by

*Reasons for today visit

How will you pay for the service?

Cash

Check

Credit Card

Is your dental insurance either PPO or HMO? Yes

Who will pay for the service?* Mother

Father

Self

Spouse

Other

*In case of emergency who should we contact?

*Emergency Person Phone

Relationship

Dental Insurance Information

Employer

Plan Name

Insurance Name

Address

City

State

Zip

Phone

Policy I.D. Number

Group Number

Group Name

Insured First Name

Insured Last Name

Relation to the patient

Birth Date

Insured Person Address

City

State

Zip

Phone

Medical Insurance Information

Plan Name

Insurance Name

Phone

Policy I.D. Number

Group Number

Group Name

Insured First Name

Insured Last Name

Relation to the patient

Birth Date

Insured Person Address

City

State

Zip

Phone

Health History

*Your weight

*Your height

Has anything happened to your health?

Yes

Do you currently have any physician care?

Yes

Have you had any illness, surgeries or been hospitalized in the past five years?

Yes

Do you have any implant?

Yes

Have you ever had a heart valve replacement or vascular graft?

Yes

Have you ever had any strange reactions to anesthesia?

Yes

Do you need to take any antibiotics before dental treatment?

Yes

Is there any health concerns that doctor should know about?

Yes

Is there anything you should tell doctor before the treatment?

Yes

Rheumatic fever

Yes

Damaged heart valves?

Yes

Heart murmur?

Yes

High blood pressure?

Yes

Low blood sugar?

Yes

Kidney problem?

Yes

High cholesterol?

Yes

Are you on dialysis?

Yes

Arthritis or joint disease?

Yes

Osteoporosis

Yes

Osteonecrosis

Yes

Stomach ulcers

Yes

Contagious diseases

Yes

Sexually transmitted disease

Yes

Immune system issues?

Yes

Healing delay

Yes

Tumors?

Yes

Cancer, Radiation Therapy or Chemotherapy

Yes

Chronic fatigue

Yes

Alcoholic problem?

Yes

Drug problems?

Yes

Are you wearing any contact lenses?

Yes

Eye diseases?

Yes

Depression or anxiety?

Yes

Removable dental appliance?

Yes

Jaws pain when eating?

Yes

Stroke

Yes

Thyroid trouble

Yes

Diabetes

Yes

Low blood pressure

Yes

Chest pain

Yes

Heart attack

Yes

Irregular heart beat

Yes

Cardiac pacemaker

Yes

Heart surgery

Yes

Pneumonia, Bronchitis or Chronic Cough

Yes

Asthma

Yes

Hay fever / sinus problems

Yes

Snoring / sleep apnea

Yes

Difficult breathing or lung problem?

Yes

Tuberculosis

Yes

Emphysema

Yes

Do you smoke?

Yes

Do you use chewing tobacco?

Yes

Blood transfusion

Yes

Blood disorder

Yes

Bruises?

Yes

Bleeding tendency / abnormal bleed

Yes

Hepatitis, jaundice, or liver disease

Yes

Infectious mononucleosis

Yes

Gallbladder problems?

Yes

Faint

Yes

Convulsions or epilepsy

Yes

Does anyone in your family have a history of cancer?

Yes

Does anyone in your family have a history of diabetes?

Yes

Does anyone in your family have a history of heart disease?

Yes

Does anyone in your family have a history of anesthetic problems?

Yes

Are you on any medications?

Yes

Are you now taking Blood thinners?

Yes

Have you ever taken tranquilizers, sleeping pills, anti depressants and/or narcotics on a regular basis?

Yes

Are you taking Aspirin?

Yes

Are you taking Amoxicillin?

Yes

Any narcotics?

Yes

Other medications?

Yes

*Please list any known allergies

*List of current medications

*Ever taken any bone density bone medications like Fosamax, Boniva, Actonel? If yes, how long?

Signature

Print Full Name here

Date: June 14, 2025

* Enter the code below

Oral Surgery & Dental Implant Center

Patient Information

Dental Insurance Information

Medical Insurance Information

Health History

Signature