Submit and Update Your Contact I

Submit and Update Your PATIENT
Contact and Health Information

Background music: Ashokan Farewell from the original soundtrack recording of
Ken Burn's "The Civil War" series on Public Television; composed by Jay Ungar,
performed by Evan Stover, Jay Ungar, Matt Glaser, Molly Mason, and Russ Barenberg.

Save time filling out forms when you visit our office. Use our online forms to send us your account and patient information.

When done submitting Patient information, close this window to return to the information update page.

Just complete the Patient Information form below and click the [Submit Information] button at the bottom of the page. We need a separate Patient Information form for each person in your account. Please fill out the form completely, since any information you don't submit here will probably need to be collected from you next time you're in our office.

YOUR PATIENT INFORMATION

Name of person completing this form:		*(Required)*
NOTE: When the words "you" and "your" are used in the questionnaire below, those words refer to the patient whose information form is now being filled out, not necessarily the person who is actually filling out the form!

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you. Please submit to us a separate Patient Information Form for each person in your account.

Patient's FULL Name:		*(Required)*
Name You Prefer To Be Called By:

Your E-mail address:		(We won't release your e-mail address to anybody. We hate spam and junk mail even worse than you do!)
Street Address or Box Number:
City:
State:
Zip:

Home Phone Number:
Cell/Mobile Phone Number:
Work or Other Contact Phone Number:

Birth Date:
Referred to Our Office By:

The information below is required if you want us to submit insurance claims for you...
Social Security Number:
Patient's Marital Status:		Single Married Divorced Widowed Separated
If Married, Name of Spouse:
Insurance ID Number: (Patient's Blue Cross Number, Medicaid Number, etc.)

Dental History Please give a full explanation for each question below.
Purpose of this patient's visit to the dentist:
Any unhappy past dental experiences?
Any complications with tooth extractions or other dental surgeries?
If we could do anything to enhance the your smile's appearance, what would you like to have changed?
Do you have a problem with bad breath you'd like help with?		Yes
Do your gums bleed when brushing or flossing?		Yes
Have you had any special "gum treatments" in the past?
Have you had your teeth straightened (orthodontics)?		Yes
Do you have a problem with clenching or grinding your teeth?
Have you noticed a lump or swelling in your mouth?
Is fear of dental treatment a substantial probelm for you?
How long has it been since you last saw a dentist?
What was done at your last dental visit?

Medical History Please give a full explanation for each question below.
Your physician's name and address:
If you currently under the care of a physician, please explain about that:
List all medications you are taking now:
After tooth extractions or other dental surgeries, have you ever had prolonged bleeding requiring special treatment?
Please give details of any allergies you may have, and any unusual reactions you have had to an anesthetic or drug:
Have check any of the following medications you have taken in the last 5 years?
Fosamax Bondronat Actonel Zometa Aredia Neridronate Olpadronate Didronel Bonefos Skelid Bisphosphonate
Please mark below any diseases or other problems you have, or have had...
Rheumatic fever Infectious hepatitis Jaundice Tuberculosis Diabetes Epilepsy Heart disease or attack Blood pressure trouble Stroke Glaucoma Kidney or liver trouble Asthma	Mitral valve prolapse Angina Pacemaker Artificial joints Artificial valves Ulcers Emphysema Thyroid disease Cancer X-ray treatment for cancer Cobalt treatment for cancer Chemotherapy		HIV+ / AIDS Hemophilia Cold sores / fever blisters Psychiatric treatment On special diet Shortness of breath Swelling of ankles during day Congenital heart defect Heart surgery Anemia Must be propped up to sleep Severe or frequent headaches

For Women: Are you pregnant? If yes, what month of pregancy are you in?			Yes
Are you nursing?			Yes

Please type here any additional comments or information you need to send to us:

Thanks for the time to answer all these questions! It really helps us do a better job.