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4620 E Douglas, Suite 100Wichita, KS 67208
Please fill out these formscompletely. The better we
communicate, the better we can care for you.
PAUDEN_111 (11/15)
Terra Pauly D.D.S
The benefits of a happy,healthy smile are immeasurable! Our goal is tohelp you reach and maintain maximum oral health.
About YouTodays Date:
Name:
I prefer to be called: Male Female
Birth date: Age: SS#:
Home Address
Single Widowed Married Divorced Separated
Home#: Work#:
Cell#: Email:
Employer:
Employer’s Address:
How long there? Occupation:
Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:
Previous / Present Dentist:
Last Visit Date:
Last First MI Mr. Mrs. Ms. Dr.
APT/CONDO#
City State Zip
1.Primary Dental Insurance
Insurance Company Name:
Insurance Co. Address:
Insurance Co. Phone#:
Group # (Plan, Local or Policy #):
Insureds Name: Relation
Insureds Birthday: Insureds SS#:
Insureds Employer:
Orthodontic Coverage? Yes No
Secondary Dental Insurance
Insurance Company Name:
Insurance Co. Address:
Insurance Co. Phone#:
Group # (Plan, Local or Policy #):
Insureds Name: Relation
Insureds Birthday: Insureds SS#:
Insureds Employer:
Orthodontic Coverage? Yes No(PLEASE CIRCLE)
Spouse Information2.Name:
Employer:
Work#: Cell#:
D.O.B.: SS#:
Person Responsible for Accounts:
Work #: Ext HM#:
Billing Address:
Relationship: SS#:
Employer: DL#:
Dental Insurance3.
In the event of an emergency, is there someone who lives near you that we should contact?
Their Name: Relation:
Work#: Home#:
Medical History4. Do you have a personal physician? No Yes
Physician’s Name:
Phone #: Date of last visit:
CONTINUED ON BACK OF FORMI hereby authorize payment directly to the below name dentistof the group insurance benefits otherwise payable to me. SIGNED (Insured Person)
PAUDEN_111 (11/15)
OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY
I verbally reviewed the medical / dental information above
with the parent / guardian & patient named herein.
Initials Date
Doctor’s Comments:
Medical History Update
1. Date Signature:
Billing Address:
2. Date Signature:
Billing Address:
Medical History (continued)
Your current physical health is: Good Fair Poor
Are you currently under the care of a physician? Yes No
Please explain
Are you taking any prescription / over-the-counter drugs? Yes No
Please list each one
For Women: Are you taking birth control pills? Yes No
Are you pregnant? Yes No Week#
Are you nursing? Yes No
4.Primary Dental Insurance
Why have you come to the dentist today?
Are you currently in pain? Yes No
Have you ever had a serious / difficult problem associated with any previous dental work? Yes No
Do you now or have you ever experienced pain or discomfort in your jaw joint (TMJ/TMD)? Yes No
Your current dental health is: Good Fair Poor
Do you like your smile? Yes No
Do your gums ever bleed? Yes No
How many times a week do you floss?
How many times a day do you brush?
Type of bristles? Hard Medium Soft
Dental History5.
Have you ever had any of the followingdiseases or medical problems?
Y N Heart Attack / Stroke Y N Tuberculosis (TB)Y N Cancer / Chemotherapy Y N Drug / Alcohol AbuseY N Heart Murmur Y N Venereal DiseaseY N Rheumatic Fever Y N Hemophilia/Abnormal BleedingY N HIV+ / AIDS Y N Ulcers / ColitisY N Heart Surgery / Pacemaker Y N Congenital Heart defectY N Shingles Y N Anemia/Radiation TreatmentY N Mitral Valve Prolapse Y N Asthma/ArthritisY N Kidney Problems Y N Difficulty BreathingY N Artificial Bones/Joints Y N Hospitalized for Any ReasonY N Sinus Problems Y N HepatitisY N High/Low Blood Pressure Y N Blood TransfusionY N Fever Blisters/Canker Sores Y N Emphysema/GlaucomaY N Severe/Frequent Headaches Y N Scleroderma/LupusY N Psychiatric Problems Y N FibromyalgiaY N Epilepsy/Seizures/Fainting Spells Y N Multiple SclerosisY N Hypoglycemia/Diabetes Y N Tobacco Use
Are you taking or have you ever taken any medication for Osteoporosis or cancer, either orally or by IV?
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following drugs or foods?Y N Penicillin Y N Codeine Y N NutsY N Aspirin Y N Latex Y N StrawberriesY N Erythromycin Y N Sulfa Y N AvacadoesY N Tetracycline Y N Other Y N KiwiY N Dental Anesthetics
Please List any other drugs that you are allergic to:
understand that the information that I have given today is
correct to the best of my knowledge. I also understand that this informa-
tion will be held in the strictest confidence and it is my responsibility to
inform this office of any changes in my medical status. I authorize the
dental staff to perform any necessary dental services with my informed
consent that I may need during diagnosis and treatment.
SIGNATURE DATE
I
Payment is due in full at the time of treatment unlessprior arrangements have been approved.
Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.
!
Our office is committed to meeting or exceeding the standards ofinfection control mandated by OSHA, the CDC and the ADA