Patient Information

Patient Name

First NameMiddle NameLast Name

Preferred Name or Nickname

Patient Gender

Preferred Pronouns

Address

Street Address Line 2

CityState

ZIP

SSN

Patient Date of Birth:

Preferred Phone#

Format: (000) 000-0000.

Patient E-mail

example@example.com

Marital Status:

If you are a student, are you:

Whom may we thank for referring you to Irvine Lake Dental?

Subscriber Name

Relationship to Subscriber

Subscriber Date of Birth:

Subscriber SSN

Subscriber Address (If same as your address, write 'same as above')

Insured Address

Street Address Line 2

CityState

ZIP

Subscriber E-mail

example@example.com

Name of Insurance Company

Subscriber ID #

Group ID #

Insured Employer Name

Occupation

Authorization and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Lake Dental Group of Hak Won Kim DMD Inc, and David H Kim DDS Inc all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the Lake Dental Group of Hak Won Kim DMD Inc, and David H Kim DDS Inc to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature

Date

Are you currently under the care of a physician?

If yes, Physician's Name

Date of Last Visit

Date

Physician's Phone

Format: (000) 000-0000.

Is your current physical health:

Are you taking any prescription or over the counter medications?

If yes, please list

Do you use tobacco in any form?

Have you ever taken Fosamax or any other bisphosphonates?

For women only: Are you pregnant?

If yes, how many weeks?

For women only: Are you currently nursing?

For women only: Are you taking birth control?

Do you have, or have had any of the following?

Rows	Yes	No
Anemia
Artifcial Joints/Valves
Arthritis
Asthma
Blood Transfusion
Cancer/Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug/Alcohol Abuse
Epilepsy / Seizures / Fainting
Emphysema
Fever Blisters/Herpes
Heart Attack/ Stroke
Heart Murmur
Heart Surgery/Pacemaker
Hemophilia/Abnormal Bleeding
Hepatitis
High or Low Blood Pressure
HIV / AIDS
Hospitalization for any reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Treatment
Radiation Therapy
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickle Cell Disease
Sinus Problems
Tuberculosis (TB)
Ulcers / Colitis
Venereal Disease

Please list any medical condition(s) that is not listed

Are you allergic to any of the following?

Rows	Yes	No
Acrylics
Aspirin
Anesthetics
Codeine
Erythromycin
Jewelry / Metals
Latex
Penicillin
Tetracycline

Please list any other drugs or materials you are allergic to:

Why are you visiting our office today?

Do you require antibiotics before treatment?

Are you in pain?

Have you ever had a serious or difficult problem associated with previous dental work?

Do you have pain or discomfort with your jaw joint? (TMJ/TMD)

Do your gums bleed?

How many times do you floss per week?

Brush per day?

When was your last dental visit?

Last dental cleaning?

Authorization

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform Lake Dental Group of Hak Won Kim DMD Inc, and David H Kim DDS Inc of any changes in my medical status. I authorize the dental Lake Dental Group of Hak Won Kim DMD Inc, and David H Kim DDS Inc and their staff to perform the necessary dental services that I may need.

Signature

Date

Patient Information

Insurance Information

Medical History

Dental History