W E L C 0 M EPATIENT INFORMATION DENTAL INSURANCEDale Who is responsible for this account?

SSN/HIC/Patient 10# Relationship to patient

, -Patient Insurance Co.

Address Group #

City Is patient covered by additional insurance? OVes ONo

State Zip Subscriber's Name

E-mail Birthdate SSN#

Sex OMaie o Female Age Relationship to Patient

Birthdate Insurance Co.

oMarried oWidowed oSingle oMinor Group #

oSeparated o Divorced oPartnered for ___ Vrs. ASSIGNMENTAND RelEASEI certify that I, and/or my dependent(s), have insurance coverage

Occupationwith:

Patient Employer/Schooland assigndirectly to Dr.

Employer/School Address all insurance benefits, if any, otherwise payable to me forservices rendered. I understand that I am financiallyresponsible for all charges whether or not paid by insurance. Iauthorize the use of my signature on all insurance forms.

Employer /School Phone (----.l .The above named doctor may use my health care information and

Spouse's Name may disclose such information to the above-named InsuranceCompany(ies) and their agents for the purpose of obtaining

Birthdate payment for services and determining insurance benefits or thebenefits payable for related services. This consent will end when

SSN# my current treatment plan is completed or on year from the datesigned below.

Spouse's Employer

Whom may we thank for referring you? Signature of Patient, Parent, Guardian or Personal Representative

How did you hear about us?Pleaseprint name of Patient, Parent, Guardian or Personal Representativeo Radio oWebsite o Friend o Relative

oOther Date Relationship to Patient

PHONE NUMBERSHome ( ) Work~ Ext Cell Phone (----.l

Spouse's Work ( ) Best time and place to reach you

IN CASEOF EMERGENCY,CONTACT(Specify someone who does not live in your household.)

Name Relationship

Home Phone ( ) Work Phone ( )

DENTAL HISTORY

Reason for today's visit Burning sensation on tongue OVes ONo Mouth Breathing OVes ONoChew on one side of mouth OYes ONo Mouth pain, brushing oYes ONoCigarette, pipe, or cigar smoker OYes ONo Orthodontic treatment oYes ONo

Former Dentist Clicking or popping jaw OYes ONo Pain around ear oYes ONoDry Mouth OYes ONo Periodontal treatment oYes ONo

City/State Fingernail biting OVes ONo Sensitivity to cold oYes ONoFood collects between teeth OYes ONo Sensitivity to heat OVes ONo

Date last dental visit Foreign objects OYes ONo Sensitivity to sweets oYes ONoGrinding teeth OYes ONo Sensitivity when biting OVes ONo

Date last dental x-rays Gums swollen or tender OYes ONo Sores in mouth oYes ONoJaw pain or tiredness OYes ONo

Place a mark on "yes" or "no" to indicate if Lip or cheek biting OYes ONo How often do you floss?you have had any of the following: Loose teeth or broken fillings OYes ONoBad Breath OYes ONo How often do you brush?Bleeding gums OYes ONoBlisters on lips or mouth OYes ONo

HEALTH HISTORY

Physician's Name Date of last dental visitHave you ever taken ahy of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names ofPhentermine), Podimin (fenfluramine) and Redux (dexfenfluramine). 0Yes ONoPlace a mark on "yes" or "no" to indicate if you have had any of the following:

, -AIDS/HIV OVes ONo Epilepsy OVes ONo Respiratory Disease OVes ONo

Anemia OVes ONo Fainting or dizziness OVes ONo Rheumatic Fever OVes ONoArthritis, Rheumatism OVes ONo Glaucoma OVes ONo Scarlet Fever OVes ONoArtificial Heart Valves OVes ONo Headaches OVes ONo Shortness of Breath OVes ONoArtificial Joints OVes ONo Heart Murmur OVes ONo. Sinus Trouble OVes ONo

Asthema OVes ONo Heart Problems OVes ONo Skin Rash OVes ONo

Back Problems OVes QNo Hepatitis Type __ OVes ONo Special Diet OVes ONo

Bleeding abnormally, with OVes ONo Herpes OVes ONo Stroke OVes ONo

Extractions or surgery OVes ONo High Blood Pressure OVes ONo Swollen Feet or Ankles OVes ONoBlood Disease OVes ONo Jaundice OVes ONo Swollen Neck Glands OVes ONoCancer OVes ONo Jaw Pain OVes ONo Thyroid Problems OVes ONo

Chemical Dependency OVes ONo Kidney Disease OVes ONo Tonsillitis OVes ONoChemotherapy OVes ONO liver Disease OVes ONo Tuberculosis OVes ONoCirculatory Problems OVes ONo Low Blood Pressure OVes ONo Tumor or growth on head/neck OVes ONoCongenital Heart Lesions OVes ONo Mitral Valve Prolapse OVes ONo Ulcer OVes ONoCortisone Treatments OVes ONo Nervous Problems OVes ONo Veneral Disease OVes ONoCough, Persistent or bloody OVes ONo Pacemaker OVes ONo Weight Loss,unexplained OVes ONoDiabetes OVes ONo Psychiatric Care OVes ONoEmphysema OVes ONo Radiation Treatment OVes ONo

Do vou wear contact lenses? OVes ONO

Women:Are you Pregnant? OVes ONO Due Date Are you nursing? OVes ONo ,

MEDICAnONS ALLERGIESlist any medications you are currently taking and the correlating oAspirin o Local Anestheticdiagnosis:

o Barbiturates (sleeping pills) o Penicillin

oCodeine oSulfa

Pharmacy Name o Iodine oOther

Phone(~ o Latex

UPDATES (Tobe filled in at future appointments)

Has there been any change in your health since your last dental appointment? o Yes ONo

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature Date

Doctor's Signature Date

Has there been any change in your health since your last dental appointment? OVes ONo

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature Date

Doctor's Signature DateHas there been any change in your health since your last dental appointment? OVes ONo

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature Date

Doctor's Signature Date