Perio Implant Health Professionals

A Dental Practice

Angel Emmanuel Rodriguez, DDS, CAGS, MSD, William Matoska, DDS. APDC, Joan Otomo-Corgel, DDS, MPH, FACD, APDC

1127 Wilshire Blvd., Suite 1110, Los Angeles, CA 90017 Tel: (213) 481-0664 Fax: (213) 481-2902

Dental Implants, Esthetic Regenerative Periodontics, Oral Medicine

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Age

Sex

MaleFemale

California Driver's License #:

Driver's License NumberExpiration Date

Marital Status:

Patient's Occupation:

Soc. Sec. No.

Patient Employed by:

Business Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Cell Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Spouse's Name:

First NameLast Name

Spouse's SSN:

Spouse's Date of Birth:

Date

Spouse Employed by:

In Case of Emergency, who should we contact?

Emergency Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is your relationship with the emergency contact?

Who referred you to our office?

Do you have dental insurance?

YesNo

Insurance Company Name and Group #

Insurance Company NameGroup Number

Do you have dual coverage?

YesNo

Insurance Company Name and Group #

Insurance Company NameGroup Number

To avoid misunderstanding regarding dental insurance, we wish our patients to know that ALL PROFESSIONAL SERVICES RENDERED are CHARGED DIRECTLY TO PATIENT and that PATIENTS ARE PERSONALLY RESPONSIBLE FOR PAYMENTS OF ALL FEES. We will prepare the necessary forms or reports to help you obtain your benefits from insurance companies. We do not render our services on the basis that insurance companies will pay our fees.

Who is your regular dentist?

Date of last visit?

Date

Has your dental care been:

Regular (Yearly)Intermittent (when necessary)Infrequent (when in pain)

Approximate date when your teeth were last cleaned?

Date

Have you had gum/periodontal therapy in the past?

NoYes, please enter when below

If you've had gum/periodontal therapy, was it with a:

With A PeriodontistWith general D.D.S.

What aids do you use to clean your teeth and gums?

Have you ever had any of the following?

TMJOrthodontics (Braces)Endodontics (Root Canal)If so, when?

Have you had an unpleasant experience in a dental office?

NoYes (Please explain below)

Would you be very disturbed if you has to lose your teeth and wear false teeth?

NoYes

Are you dissatisfied with the appearance of your teeth?

YesNo

Have you ever experienced any of the following?

Is there sensitivity in your teeth? If yes, check all that apply:

Have you ever has an injury or pain to your face, neck, or jaws?

YesNo

Any other comments?

Periodontal disease is caused by a combination of complex factors and successful treatment depends upon their identification. Even though some of these question seem unrelated to your periodontal condition, they are all associated with proper oral health care. Please answer all questions. Circle yes or no, whichever applies. All answers are confidential.

How is your general health?

Date of last physical examination?

Date

What is your height?

What is your current weight?

Physician's Name:

Physician's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Physician's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you being treated by a physician or psychiatrist now?

PhysicianPsychiatrist

Are you taking any drugs or medications?

Are you allergic or have you experienced an unusual reaction to any drugs?

Have you ever been seriously ill or hospitalized?

NoSeriously illHospitalizedIf so, explain:

Do you have heart trouble?

Have you had any serious infectious disease?

Have you had any of the following?

Have you had abnormal bleeding associated with extractions, surgery, or menstruation?

YesNo

Have you ever had a blood transfusion?

YesNo

Do you have any allergic conditions?

NoAsthmaSkin rashes, hivesSinus problems, hayfever

Is there a tendency towards any illness in your family?

NoDiabetesHeart troubleOther

Do you have any disease condition, or problem not listed that we should know about?

NoYes, please explain:

Do you smoke or chew tobacco? If so, how much or pack/day?

Do you prefer sedation for your periodontal therapy?

NoIntravenous sedationOral sedationN2O2

Women, are you pregnant?

YesNo

Signature of Patient, Parent or Guardian

Today's Date

Date

Hour MinutesAM/PM Option

I understand that where appropriate, credit bureau reports may be obtained.

Perio Implant Health Professionals

Patient Information

INSURANCE

MEDICAL HEALTH HISTORY

PLEASE INFORM THE DOCTOR IF YOUR HEALTH CHANGES IN ANY WAY

Perio Implant Health Professionals

Primary Dental Insurance

Secondary Dental Insurance (If Applicable):