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832-644-8585
office@mdendodontics.com
Please, provide the following information in order to have access to our forms. Thank you!
Expert Passion for a Healthy Smile
Salutation:
First Name:
Last Name:
M.I. :
Home Phone:
Cell Phone:
Date of Birth:
Work Phone:
Fax:
Gender:
Home Address:
City/State/Zip:
Social Security Number:
Emergency contact:
Home email:
Emergency contact Phone:
Work E-mail:
Employer Name:
Family Physician
Employer Address:
Family Physician Phone:
Family Dentist
Date of Last Physical Exam
Referring Dentist
Height:
Weight:
Circle where messages can be left:
Insurance Company:
Policy Holder’s Name:
Insurance address:
Policy Holder’s DOB:
City/State/ZIP:
Policy Holder’s Employer:
Insurance ID:
Policy Holder’s SSN:
Group
Relationship to patient:
Yes
No
Don’t Know
1. Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? If yes, please explain.
2. Has there been any change in your general health within the past year? If yes, please explain.
3. Are you under the care of a physician for a current problem? If yes, explain.
4. Have you been hospitalized within the past 5 years? Please specify.
5. Have you received therapy for alcoholism or drug addiction during the past 5 years?
6. Have you ever had any ALLERGIC or ADVERSE REACTIONS to anesthetics, antibiotics, medications?
7. Is there any condition concerning your health that the doctor should be told?
8. Do you wish to speak to the doctor privately about anything?
9. Have you had abnormal bleeding with previous extractions, surgery, or trauma?
10. Have you ever required a blood transfusion?
11. Have you ever had radiation for any condition?
12. Have you ever tested positively for HIV infection or AIDS? If so, state date diagnosed and treating doctor.
13. Are you required to take antibiotics prior to dental treatment?
14. Do you have or have you had any of the following?
15. Are you taking any herbal medicine (i.e., St. John’s Wort)?
16. Have you ever taken the “fen-phen” diet pill?
17. Do you have any disease, condition or problem not listed above? Specify.
18. Are you taking bisphosphonates now or have you taken them in the past (Fosamax)?
19. Are you taking any medication or drugs? If yes, please list them below.
Possibility of pregnancy:
Nursing:
If yes, estimated delivery date:
Taking birth control pills:
Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/ gynecologist for assistance regarding additional methods of control.
This visit is related to an accident:
Work related:
Date of injury:
Insurance company handling the claim:
Claim Number: