New Patient Application Patient Information Parent or Guardian (if applicable): Birthdate: PERSON RESPONSIBLE FOR ACCOUNT DENTAL INSURANCE PRIMARY CARRIER Birthdate: DENTAL INSURANCE SECONDARY CARRIER Birthdate: PERSON TO CONTACT IN CASE OF EMERGENCY I understand that my dental insurance carrier or payor of my dental benefits may pay less than the actual bill for services. I understand I am financially responsible for payments in full of all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental care payor. I attest to the accuracy of the information on this page. Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? Select option Yes No Have you ever been hospitalized or had a major operation? Select option Yes No Have you ever had a serious head or neck injury? Select option Yes No Are you taking any medications, pills, or drugs? Select option Yes No Do you take, or have you taken, Phen-Fen or Redux? Select option Yes No Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Select option Yes No Are you on special diet? Select option Yes No Do you use tobacco? Select option Yes No Women: Are you... Select option Pregnant/Trying to get pregnant Nursing Taking oral contraceptives Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Do you use controlled substances? Select option Yes No Other? Select option Yes No Do you have, or have you had any of the following? AIDS/HIV Positive No Yes Alzheimer's Disease No Yes Anaphylaxis No Yes Anemia No Yes Angina No Yes Arthritis/Gout No Yes Artificial Heart Valve No Yes Artificial Joint No Yes Asthma No Yes Blood Disease No Yes Breathing Problems No Yes Bruise Easily No Yes Cancer No Yes Chemotherapy No Yes Chest Pains No Yes Cold Sores/Fever Blisters No Yes Congenital Heart Disorder No Yes Convulsions No Yes Yellow Jaundice No Yes Cortisone Medicine No Yes Diabetes No Yes Drug Addiction No Yes Easily Winded No Yes Emphysema No Yes Epilepsy or Seizures No Yes Excessive Bleeding No Yes Excessive Thirst No Yes Fainting Spells/Dizziness No Yes Frequent Cough No Yes Frequent Diarrhea No Yes Frequent Headaches No Yes Genital Herpes No Yes Glaucoma No Yes Hay Fever No Yes Heart Attack/Failure No Yes Heart Murmur No Yes Heart Pacemaker No Yes Heart Trouble/Disease No Yes Hemophilia No Yes Hepatitis A No Yes Hepatitis B or C No Yes Herpes No Yes High Blood Pressure No Yes High Cholesterol No Yes Hives or Rash No Yes Hypoglycemia No Yes Irregular Heartbeat No Yes Kidney Problems No Yes Leukemia No Yes Liver Disease No Yes Blood Pressure No Yes Lung Disease No Yes Mitral Valve Prolapse No Yes Osteoporosis No Yes Pain in Jaw Joints No Yes Parathyroid Disease No Yes Psychiatric Care No Yes Radiation Treatments No Yes Recent Weight Loss No Yes Renal Dialysis No Yes Rheumatic Fever No Yes Rheumatism No Yes Scarlet Fever No Yes Shingles No Yes Sickle Cell Disease No Yes Sinus Trouble No Yes Spina Bifida No Yes Stomach/Intestinal Disease No Yes Stroke No Yes Swelling of Limbs No Yes Thyroid Disease No Yes Tonsillitis No Yes Tuberculosis No Yes Tumor or Growths No Yes Ulcers No Yes General Disease No Yes Have you ever had any serious illness not listed Select option Yes No Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement. I have received a copy of this office’s Notice of Privacy Practices. I Agree 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 patient's) health. It is my responsibility to inform the dental office of any changes in medical status. Please agree with above to be able to submit this form.