“We treat you beautifully” Patient Name ___________________________________Goes by ________________________ Address ______________________________________________Apt # ___________________ City _____________State _________Zip __________Home Phone _______________________ Date of Birth _____________Social Security # ________________DL#____________________ Marital Status ________ How did you hear about the office ______________________________ Employer _________________________________Work Phone __________________________ E-Mail _________________________________________ (Used only for appointment reminders) MEDICAL AND DENTAL HISTORY What is the main problem you are here for today? ______________________________________ Are you currently under the care of a physician? ___Yes ___No Are you currently taking any drugs or medications? ___Yes ___No If yes please list. __________________________________________________________________ Allergies to Medication _____________________________________________________________ Allergies to Latex ___Yes ___No Do you have or have you ever had ? Y/N Cosmetic surgery Y/N Heart Murmur Y/N Fainting Y/N Hepatitis Y/N Mitral Valve Prolapse Y/N fibromyalgia Y/N Epilepsy, convulsions or seizures Y/N Rheumatic Fever Y/N Nervous Disorder Y/N Cortisone-Steroid Treatment Y/N Artificial Joints Y/N Heart Disease Y/N Kidney or Bladder Disease Y/N Stroke Y/N Head Injuries Y/N Diabetes Y/N Allergies Y/N Rheumatism Y/N Tuberculosis or Emphysema Y/N Aids/HIV Y/N Oral Surgery Y/N Shortness of Breath Y/N Liver Disease Y/N Anemia Y/N Respiratory problems Y/N Chemotherapy Y/N Glaucoma Y/N Swollen ankles Y/N Radiation Therapy Y/N Thyroid Trouble Y/N Chest Pains Y/N Sinus Problems/Hay fever Y/N Psychiatric Treatment Y/N Pacemaker Y/N Cancer Y/N Arthritis or Rheumatism Y/N Artificial Heart Valve Y/N Dizziness Y/N Venereal Disease Females Only Y/N Pregnant Y/N Taking Birth Control Pills Y/N Taking Hormone Medication Do you have a disease, condition, or any other health problem we have not covered Y__ N__ If yes please list. _____________________________________________________________ Date of last dental visit ___________________ What was done? _______________________ ã 2002 W.A.T. Inc All rights reserved. Reproduction and use of this form by dentists and their staff is permitted. Any other use duplication or distribution is prohibited.I authorize the dentist to perform diagnostic procedures and treatment as many be necessary for proper dental care. I understand that once I have been informed of my dental condition. Dental Attraction Center is not responsible for any complications that may occur should I fail to follow through with the recommended treatment plan. Signature ____________________________________Date ________________________ Person responsible for account Name ________________________________________Date of Birth ____________________ Address _________________________________________ Apt # _____________________ City _______________________________State __________________Zip ______________ Employer _______________________________Work Phone ________________ DL# _______________________________ SSN _________________________________ Relationship to Patient __________________________________ Is the patient a full time student ? ____Yes ____No Emergency Information: Please list the names and phone # of tow relatives not living with you that we may contact in case of an emergency. Name ______________________Relationship ____________Phone _________________ Name ______________________Relationship ____________Phone _________________ We ask that all patients read and sign our Financial policy as well as complete our patient information form prior to seeing the dentist. Payments for services are due at the time services are rendered. We accept cash, checks, credit cards and approved financing. Signature of person responsible for account ____________________________________ Date _______________________ ã 2002 W.A.T. Inc All rights reserved. Reproduction and use of this form by dentists and their staff is permitted. Any other use duplication or distribution is prohibited.
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