Patient Information

Patient Information

All Patient Forms Must Be Completed
Title*
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
May we contact you by email?*

YesNo
Patient Social Security Number*
Patient D.O.B.*

MonthDayYear
Date
Sex*
Emergency Contact*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Pharmacy*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
Insurance Information
Do you have Dental Insurance?*

YesNo
Do you have Secondary Dental Insurance?*

YesNo
Primary Insured
Subscriber Name
Subscriber SSN or ID
Date of Birth

MonthDayYear
Date
Relationship to Subscriber
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Insurance Group #
Insurance Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Insured
Subscriber Name
Subscriber SSN or ID
Date of Birth

MonthDayYear
Date
Relationship to Subscriber
Employer Name
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Insurance Group #
Insurance Phone #
Please enter a valid phone number.Format: (000) 000-0000.
*Please present your Insurance card to our patient services representative to be photocopied*
Authorization for Release of Health Records to External Parties
I authorize the disclosure of information from my treatment records to:
Name of Recipient:*
Relationship to Patient:*
I give authorization to disclose the following information:*

All treatment informationInformation specifically related to these treatment dates
I understand that I may withdraw or revoke my permission at any time. I may revoke this authorization by notifying Dr. Bob Dalsania DDS PC in writing:
Signature of Patient (or Patient Representative)*
Date*

MonthDayYear
Date
Printed Name of Patient (or Patient Representative)*
Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important relationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?*

YesNo
If yes, please explain:
Have you ever been hospitalized or had a major operation?*

YesNo
If yes, please explain:
Have you ever had a serious head or neck injury?*

YesNo
If yes, please explain:
Are you taking any medications, pills, or drugs?*

YesNo
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?*

YesNo
If yes, please explain:
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing biphosphonates?*

YesNo
If yes, please explain:
Are you on a special diet?*

YesNo
If yes, please explain:
Do you use tobacco?*

YesNo
If yes, please explain:
Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?
Are you allergic to any of the following?*

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOther
Do you use controlled substances?*

YesNo
If yes, please explain:

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

Rows	Yes	No
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Severe Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy/Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors/Growths
Ulcers
Venereal Disease
Yellow Jaundice

Have you ever had any serious illnesses not listed?*

YesNo
If yes, please explain:
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature of Patient or Guardian*
Date*

MonthDayYear
Date
Should be Empty:

Patient Information

Insurance Information

Primary Insured

Secondary Insured

Authorization for Release of Health Records to External Parties

Medical History