Patient Information

Patient Name________________________Birthdate________

Address____________________________________________

Phone Number:

Home:______________________Work___________________

Cell:________________________Email__________________

We usually confirm appoinment the day before from 9-11am

Patient Employed By:_________________________________

Name of Spouse  or Parent if minor:______________________

Please list two individual to notify in case of emergency

Name:_________________________________Phone:No____

Name:_________________________________Phone:No____

Whom may we thank for referring you?___________________

Medical History

Name and Address of Physician__________________________

___________________________________________________

All Medications (Prescription, on-prescription and illegal) that you are currently using. _______________________________

Patient Weight: ______________________________________

Medication you are Allergic to: __________________________

Are you Pregnant? __________ If yes, what month?________

Have you been treated for (Check all that apply)

         Heart disease

         Heart Murmur, Valve Damage

         Rheumatic Fever

         Joint/Organ Replacement

         Ulcer

         Stroke

         Abnormal Blood Pressure

         Immune System Problems

         Congenital Heart Lesions

         Abnormal Bleeding

         Tuberculosis/Lung Disease

         Diabetes

         Epilepsy

         Anemia

         Hepatitis

Reappointment antibiotic medication is usually required before a dental procedure, in cleaning, if you have a history of (please check each that applies.)

         Heart disease

         Heart Murmur

          Valve Damage

         Rheumatic Fever

         Joint/Organ Replacement