Wise Dental Medical History Form

Wise Dental Medical Form
Contact Information
Full Name

PrefixFirst NameMiddle NameLast Name
Preferred Name
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone (Residence)

Area CodePhone Number
Phone (Business)

Area CodePhone Number
Phone (Cell)

Area CodePhone Number
Emergency Phone Number

Area CodePhone Number
Occupation
Student at
E-mail
Person responsible for payment of account
Main reason for planned visit
Previous dentist's name
Last dental visit

MonthDayYear
Current physician's name
Current physician's phone number

Area CodePhone Number
Date of last medical visit

MonthDayYear

Insurance Information
Primary Coverage
Name of insured

First NameLast Name
Their birthdate

MonthDayYear
Employer
Insurance company
Group policy number
Effective date of insurance

MonthDayYear
ID number
Certificate / S.I.N number
Dependent number
Basic %
Major %
Ortho %
Deductible
'Dual' Coverage form on the next page ->

Insurance Information
Dual Coverage
Name of insured

First NameLast Name
Their birthdate

MonthDayYear
Employer
Insurance company
Group policy number
Effective date of insurance

MonthDayYear
ID number
Certificate / S.I.N number
Dependent number
Basic %
Major %
Ortho %
Deductible

Permission to Proceed
This is to certify that by clicking 'yes' below, I consent to the performing of the dental procedures agreed to be necessary or advisable, and I will assume responsibility for fees associated with those procedures.
Click to edit

Medical History
Are you under the care of a physician?
If so, what is the condition being treated?
Have you ever been hospitalized?
If so, what was the problem?
Are you taking any drug or medicine?
If so, what type and reason?
Are you allergic or have you reacted adversely to any drug or medicine: eg local anaesthetic (frezing); Penicillin or other antibiotics; barbiturates, sedatives, analgesics (pain killers, latex?
If so, what type of allergy?