• Health History, Consent | DR. RAY NUNNERY DDS

    301 Lennon Lane, Suite 103 Walnut Creek, CA 94598 (925)935-1933
    • Patient Information 
    • Date*
       - -
    • Sex*
    • Birthdate*
       - -
    • *

    • Partnerd for      years.

    • Format: (000) 000-0000.
    • Birthdate
       - -
    • Dental Insurance 
    • Is patient covered by additional insurance?*
    • Birthdate
       - -


    • ASSIGNMENT AND RELEASE

      I certify that I, and/or my dependent(s), have insurance coverage with   *   and assign directly to Dr.     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 insurance. I authorize the use of my signature on all insurance.

      The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

    •  
    • Date*
       - -
    • Phone numbers 
    • Rows

    • IN CASE OF EMERGENCY, CONTACT

      Specify someone who does not live in your household.
    • Format: (000) 000-0000.
    • DENTAL HISTORY 
    • Date of last dental visit*
       - -
    • Date of last dental X-rays*
       - -
    • Rows
    • HEALTH HISTORY 
    • Date of last visit*
       - -
    • Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.*
    • Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).*
    • Rows
    • Rows
    • Due date
       - -
    • MEDICATIONS 
    • Format: (000) 000-0000.
    • ALLERGIES 
    • Allergies
    • UPDATES (to be filled in at future appointments) 
    • Has there been any change in your health since your last dental appointment?
    • Date
       - -
    • Date
       - -
    • Has there been any change in your health since your last dental appointment?
    •  
    • Date
       - -
    • Date
       - -
    • Should be Empty: