MAKE AN APPOINTMENT

First Name *

Last Name *

E-mail *

Sex: Male Female *

Select your preferred time of day AM PM Anytime *

Select your preferred day(s) of the week Monday Tuesday Wednesday Thursday Friday Saturday *

Address *

City *

State *

Zip *

Birthdate *

Marital Status Married Widowed Single Minor Separated Divorced Partnered *

Occupation *

SS#

Spouse's Employer

Whom may we thank for referring you?

Home

Work

Cell

Spouse's Work

Best time and place to reach you

In case of emergency, contact:

Relationship

Home Phone

Work Phone

Who is responsible for this account?

Relationship to Patient

Insurance Company

Group #

In patient covered by additional insurance? Yes No

Subscriber's Name

Birthdate

Relationship to Patient

Insurance Company

Group #

Reason for today's visit

Former Dentist

City / State

Date of last dental visit

Date of last X-rays

Please, indicate if you have had any the following: Bad breath Bleeding gums Blisters on lips or mouth Burning sensation on tongue Chew on one side of month Cigarrette, 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 Sensitivity to sweets Sensitivity when biting None

How often do you floss?

How often do you brush?

Physician's Name

Date of last visit

Have you ever taken any of group of drogs referred to as "fen-phen"? Yes No

Please, indicate if you have had any the following: AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally, with extrations or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or Dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
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
None

Do you wear contact lenses? Yes No

Are you pregnant? Yes No Do not apply

Due Date

Are you nursing? Yes No

Taking birth control pills? Yes No Do not apply

Do you have any allergies? Aspirin Local Anesthesic Barbiturates (Sleeping Pills) Codeine Iodine Latex Penicillin Sulfa Other None

If other, describe:

List any medications you are taking and the correlating diagnosis

Pharmacy name

Pharmacy Phone