First name*

Middle Initial*

Last Name*

Nickname

Street Address*

City*

State* State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code*

Home Phone*

Cell Phone

Work Phone

Email*

Date of Birth*

Gender* -- Select One -- Female Male

Social Security Number

Employer

Occupation

Insured's First Name

Insured's Last Name

Relationship to Insured

Date of Birth

Insured's SSN

If you have secondary insurance, please fill out the information below.

Physician's First Name

Physician's Last Name

Physician's Phone Number

Does your physician require antibiotic premedication prior to dental procedures?* Yes No

Are you allergic to the following?

Aspirin* Yes No

Please check any of the following that you have had or currently have

AIDS/HIV Positive* Yes No

Abnormal Bleeding/Hemophilia* Yes No

Acid Reflux (GERD)* Yes No

Alzheimer's Disease* Yes No

Anaphylaxis* Yes No

Anemia* Yes No

Angina* Yes No

Arthritis/Gout* Yes No

Artificial Heart Valve* Yes No

If yes, when was it placed?

Artificial Joint* Yes No

If yes, when?

Asthma/Hay Fever* Yes No

Blood Disease* Yes No

Blood Transfusion* Yes No

If yes, when?

Breathing Problem* Yes No

Bruise Easily* Yes No

Cancer* Yes No

If yes, when?

Chemotherapy* Yes No

If yes, when?

Chest Pains* Yes No

Cold Sores/Fever Blisters* Yes No

Congenital Heart Defect* Yes No

Convulsions* Yes No

Cortisone Medicine* Yes No

Diabetes* Yes No

Drug Addiction* Yes No

Easily Winded* Yes No

Emphysema* Yes No

Epilepsy or Seizures* Yes No

Excessive Thirst* Yes No

Fainting Spells/Dizziness* Yes No

Frequent Cough* Yes No

Frequent Diarrhea* Yes No

Frequent Headaches* Yes No

Genital Herpes* Yes No

Glaucoma* Yes No

Heart Attack/Failure* Yes No

If yes, when?

Heart Murmur* Yes No

Heart Pace Maker* Yes No

If yes, when was it placed?

Heart Troubles/Disease* Yes No

Hemophilia* Yes No

Hepatitis A* Yes No

Hepatitis B or C* Yes No

Herpes* Yes No

High Blood Pressure* Yes No

Hives or Rash* Yes No

Hypoglycemia* Yes No

Irregular Heartbeat* Yes No

Kidney Problems* Yes No

Leukemia* Yes No

Liver Disease* Yes No

Low Blood Pressure* Yes No

Lung Disease* Yes No

Mitral Valve Prolapse* Yes No

Pain in Jaw Joints* Yes No

Parathyroid Disease* Yes No

Psychiatric Care* Yes No

Radiation Treatments* Yes No

Recent Weight Loss* Yes No

Renal Dialysis* Yes No

Rheumatic Fever* Yes No

Rheumatism* Yes No

Scarlet Fever* Yes No

Shingles* Yes No

Sickle Cell Disease* Yes No

Sinus Trouble* Yes No

Spina Bifida* Yes No

Stomach/Intestinal Disease* Yes No

Stroke* Yes No

If yes, when?

Swelling of Limbs* Yes No

Thyroid Disease* Yes No

Tonsillitis* Yes No

Total Joint Replacement* Yes No

If yes, when?

Tuberculosis* Yes No

Tumors or Growths* Yes No

Ulcers* Yes No

Venereal Disease* Yes No

Yellow Jaundice* Yes No

Are there any medical conditions we have not discussed that you feel we should be aware of?

Do you use Tobacco* Yes No

If yes, what kind?

-- Select -- Cigarettes Chewing Tobacco Both Cigarettes and Chewing Tobacco

If yes, how much?

Do you use controlled substances or have in the past?* Yes No

Women: Are you Pregnant or Trying to get Pregnant?* Yes No

If you're pregnant, how many weeks?

Taking oral contraceptives* Yes No

Nursing* Yes No

Is your water fluoridated?* Yes No

Please check any of the following which apply to you, and add any relevant comments