EmailMe Form - Southcommon Dental Patient History

Personal Information
Date
DD / MM / YYYY
Name
First Middle Last
Email
Gender
Male
Female
Other
Marital Status *
Date of Birth
DD / MM / YYYY
Age
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Home Phone
### - ### - ####
Office Phone
### - ### - #### Ext. ###
Cell Phone
### - ### - ####
Name of person responsible for this account
First Last
Do you have dental insurance?
Yes
No
Name of Policy Holder
Employer's Name
Insurance Company
Group Number
Suffix/Division Number
Certificate or Subscriber ID
Whom may we thank for referring you?
Medical History
Physician's Name
Physician's Phone Number
### - ### - ####
Have you been under the care of a doctor or clinic within the last 6 months for any treatment or observation?
Yes
No
Are you now taking or receiving any drugs or medications?
Yes
No
Please provide the drug name(s) and dosages

Have you ever had or been treated for (please check):

	X
Rheumatic Fever
Heart Murmur
Heart Trouble
Stroke
Abnormal Blood Pressure
Jaundice
Hepatitis
Liver Disease
Kidney Disease/Infection
Diabetes
Psychiatric/Mental Disorders
Epilepsy
Cancer
Ulcers
HIV/AIDS

Do you have or have you ever had an operation or any other serious illness other than the above?
Yes
No
Please elaborate.
Do you have any allergies?
Yes
No
Please list your allergies.
Have you ever had an adverse reaction to a local anesthetic?
Yes
No
Have you ever been warned against taking any medicine or drug?
Yes
No
Please list these medicines/drugs.
Do you have any abnormal bleeding problems or blood disorders?
Yes
No
Please elaborate.
Women only: Are you pregnant?
Yes
No
What is the primary reason for this appointment?
Examination
Emergency
Consultation
Dental History
Do you have a specific dental problem?
Yes
No
Please describe it.
Do you have dental examinations on a routine basis?
Yes
No
Date of last visit
Would you describe your present dental health as good?
Yes
No
Please elaborate if you wish
Do you feel nervous about having dental treatment?
Yes
No
Have you ever had a bad experience in a dental office?
Yes
No
Please describe it.
Are you happy with your smile?
Yes
No
What would you like to change?

X

Colour

Straightness

Replace missing teeth

Replace dark or discoloured fillings
Do you ever have clicking, popping or discomfort in the jaw joints?
Yes
No
Please describe it.
Has a family member been treated in this office?
Yes
No
Method of Payment
If the responsible party does not currently have an account with this office, please check one of the following:
Payment in full at each appointment
Financial arrangement for non-insured expenses (upon approval)
Visa
Mastercard
Debit
Authorization
I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical and dental histories are correct to the best of my knowledge. I understand that my dental insurance (if insured) is a contract between the insurance carrier and me, and not between the insurance carrier and the dentist, and that I am still responsible for all dental fees. I understand that I will be charged for all dental treatment, and that any payments received by the Dental Office from my insurance company will be credited to my account, or refunded to me if I have paid the dental fees incurred.
Signature
Clear
Date Time
DD / MM / YYYY

	X
Colour
Straightness
Replace missing teeth
Replace dark or discoloured fillings

Personal Information

Medical History

Dental History

Method of Payment

Authorization