• Image field 3

  • Important Instructions. Please Read.

    Please fill out this form in its entirety and remember to arrive 10 minutes before your scheduled appointment time
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year

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

  • Heart Attack, Chest Pains, Angina - Nitro Tabs*
  • Diabetes, Diet Controlled, Insulin*
  • Heart Murmur, Mitral Valve Prolapse (MVP)*
  • Rheumatic Heart Fever, Artifical Heart Valves*
  • Cancer*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Arthritis*
  • High or Low Blood Pressure*
  • Kidney Disease*
  • Bypass or Angioplasty*
  • Smoker, Emphysema, C.O.P.D, Asthma*
  • Pacemaker*
  • Ulcers, Colitis, Intestinal Disorders*
  • Stroke*
  • Herpes or Cold Sores, Canker Sores*
  • HIV or Aids*
  • Allergies (Penicillin, Erythromycin, Latex Gloves)*
  • Liver Disease, Hepatitis A, or B, or C*
  • Artificial Joints (Hip, Knee, Other)*
  • Epilepsy or Seizures*
  • Currently Pregnant, Nursing, Birth Control*
  • Blood Transfusions, Hospitalized Last 2 Years*
  • Osteoporosis, Bisphosphonate Medication*
  • Apnea Snoring (Do you have a CPAP Machine?)*
  • Do you feel well?*
  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Image field 33

  • Consent for Release of Medical Records and Information

  • By signing this form, you are granting consent to Dr. Stephen Blank and Staff to use and disclose your protected health information for the purpose of treatment, payment, referral, insurance, and healthcare operations. Our Notice of Privacy Practice (NOPP) provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our NOPP before you sign this consent, and we encourage you to read it in full.

    I authorize Dr. Blank and his practice to send unencrypted email regarding my dental health, medical conditions, and radiographs (x-rays)to other healthcare practitioners or insurance companies as needed for referrals and for transfer of my records to myself (patient) or anyone the patient directs.

    I authorize Dr. Blank and/or Staff to call, text, or email appointment reminders and other care-related messages to my:

  • Choose all that apply*

  • I understand I can withdraw my consent at any time.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I authorize Dr. Blank and/or his staff to permit the following individuals to enter the treatment room, discuss my care (in person or by phone), and receive information about my treatment:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Image field 85
  • Should be Empty: