New Image Dentistry Med History

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Work Phone

Home Phone

Cell Phone

E-Mail*

Do you have a personal physician?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Are you currently under the care of a physician?

YesNo

If yes, please explain

Do you use tobacco in any form?

YesNo

If yes, please list type and frequency of use

Do you have any artificial joints or implants?

YesNo

If yes, please list along with date of surgery

Are you taking any medication?*

YesNo

If yes, please list each one*

Have you ever had an allergic or unusual reaction to any of the following?

	Yes	No
Latex Materials?
Penicillin?
Erythromycin or Other Antibiotics?
Sulfa Drugs/Sulfittes/Sulfides
Any other Medication or Drugs?
Aspirin?
Ibuprofen?
Codeine?
Local Anesthetics (i.e., Novocaine Lidocaine)?
Other Dental Materials

List all known allergies

Do you have any of these conditions?

	Yes	No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Bisphosphonates
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

If Female, do you have any of these conditions?

	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If you are pregnant, how many weeks?

Do you have any diseases, conditions or problems that you feel we should know about? If so, please describe*

( Physical signature obtained at Dental office.)

Print Name: ____________________________________________

Responsible Party Signature: __________________________ Date:______________

Doctor Signature: ___________________________________ Date:______________

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to New Image Dentistry, 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 New Image Dentistry 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.

Disclaimer:

All office personnel are New Image Dentistry employees, except the Doctor. The Doctor is a licensed Dentist in the State of Arizona, but is an independent contractor. The Doctor and you, without input from anyone else, will determine the Dental services and treatment to be performed on you.

I understand that the Doctor is an independent contractor at New Image Dentistry and not an employee.

( Physical signature obtained at Dental office.)

Print Name: ____________________________________________

Responsible Party Signature: _____________________________ Date:__________

New Image Dentistry Patient Information

Medical History

Assignment and Release