Bridgeport Dentistry - 1 Year Update

Bridgeport Dentistry 1-Year Update
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Phone Number

Area CodePhone Number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFO:
PRIMARY DENTAL INSURANCE
Name of Insurance Company
Group # and ID #

Group NumberID Number
A Quick Self Assessment: I consider my health to be (check one):
Do you or have you had any of the following? (Check all that apply):
Do you smoke or use chewing tobacco?

Other
Have you drank alcohol in the last 24 hours?
I usually take an antibiotic prior to dental treatment?
Have you ever taken Fen-Phen or Redux?
Do you take or have you ever taken Biophosphates (Fosamax, Boniva, Actonel, Aredia, Zometa, etc.) for Osteoporosis or any other condition?
Have you had a major surgery?
If so, please list year of surgeries, and the type of operation(s):
Have you had liver Disease?
Please check if you've had any of the following. Please check all that apply:
Do you have any other medical problem or medical history NOT listed on this form?

Other
FOR WOMEN:
Are you taking birth control medication?
Are you or could you be pregnant or nursing?
MEDICINE OR DRUG ALLERGY
Are you allergic to any of the following? Please check all that you are allergic to:

Other
Please list all medications you are currently taking and the condition you are taking it for:
Who is your medical Doctor?
Doctor's Name
Medical Doctor's Phone Number

Area CodePhone Number
Medical Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Info:
Emergency Contact #1:
Whom should we contact?
Name of Emergency Contact
Relation
How do you know this person
Their Cell Phone Number

Area CodePhone Number
Emergency Contact #2:
Whom should we contact?
Name of Emergency Contact
Relation
How do you know this person
Their Cell Phone Number

Area CodePhone Number
Sign below:
Should be Empty: