Download Printable Version 290 Ferry Street, Suite B2, Newark NJ 07105 - Telephone: (973) 817-8888 - Fax: (973) 465-1955www.getsmile.net Today’s Date: MM slash DD slash YYYY To protect your privacy, our office follows legal policies and procedures. Your responses are confidential and used solely for our records. We may ask follow-up questions about your health to ensure appropriate care. We do not use this information to discriminate.PERSONAL INFORMATIONPatient's First & Last NameSSNDate of Birth MM slash DD slash YYYY Gender Male FemaleAddress Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneCell PhoneWork PhoneEmployerEmail Marital Status Married Single OtherLegal guardian name (If patient is under age of 18) :How did you hear about this office? TV Radio Print Internet Billboard OtherDENTAL INSURANCE INFORMATIONInsurance companyPrimary Insured's NameInsured's SSN or ID #D.O.B MM slash DD slash YYYY MEDICAL INSURANCE INFORMATIONInsurance companyPrimary Insured's NameInsured's SSN or ID #D.O.B MM slash DD slash YYYY EMERGENCY CONTACTIn case of emergency, who should we contact?NamePhoneRelationshipMEDICAL HISTORY1. The name, address and phone number of my physician2. As far as you know, are you in good health? Yes NoDo you have, or have you had any of the following:A. Rheumatic fever or rheumatic heart disease? Yes NoB. Congenital heart disease? Yes NoC. Cardiovascular disease ( heart trouble, heart attack, high blood pressure, low blood pressure, arteriosclerosis, angina, stroke) Yes NoD. A Cardiac pacemaker Yes NoE. Sinus Trouble Yes NoF. Asthma, hey fever Yes NoG. Neurological disorder, example ( Epilepsy, seizures, fainting) Yes NoH. Diabetes Yes NoI. Liver Disease, example ( Hepatitis or Jaundice) Yes NoJ. Arthritis Yes NoK. Stomach disease example ( Ulcers) Yes NoL. Intestinal Disease example ( Polyps) Yes NoM. Kidney Disease Yes NoN. Lung Disease example ( Tuberculosis, Pneumonia) Yes NoO. Veneral disease Yes NoP. Blood disease example (Anemia) Yes NoQ. Is there someone in your family with diabetes? Yes NoR. Following and injury, do you bleed excessibly? Yes No3. Have you been hospitalized for any serious condition? Yes NoIf yes, for what?4. Are you under the care of a physician? Yes NoAre you taking any of the other? Yes NoA. Antibiotics or Sulfa Yes NoB. Anticoagulants (blood thineers) Yes NoC. Medicine for high blood pressure Yes NoD. Steroids ( cortisone) Yes NoE. Tranquilizers Yes NoF. Analgesics ( pain killers, aspirin and codeine) Yes NoG. Antihistamines Yes NoH. Insulin, Orinase Yes NoI. Digitalis or drugs for hear trouble Yes NoJ. Nitroglycerin Yes NoK. Sedatives (sleeping pills, barbiturates) Yes NoL. Any others Yes No5. Are you allergic or have you had any allergic reaction to: Yes NoA. Local anesthetics Yes NoB. Penicillin or other antibiotics Yes NoC. Sulfas Yes NoD. Sedatives (sleeping pills, barbiturates) Yes NoE. Aspirin Yes NoF. Codeine or other narcotives Yes NoG. Any other allergic reactions? Yes No6. Have you been exposed to radiation recently? Yes No7. If FEMALE are you pregnant? How many months? Yes NoI understand that I am responsible to pay Gentle Dental for any treatment performed in this office, in case my insurance should neglect payment. I understand that I am responsible for any outstanding balance. I will also take responsibility for any balances due to any collection agency. If any prosthodontics ( Bridges, crowns, dentures) are not able to be completed due to patients missed appointments, the patient will be held responsible. A fee of $50 will be charged to the patient's account if cancelation notice is not given 24 hours prior to the appointment. I authorize Gentle Dental to submit dental claims to my Dental Insurance company in order to get pay for my dental treatment.Patient signature or (Legal guardian if patient is under age of 18)Date MM slash DD slash YYYY
