Date Of Birth
Gender MaleFemaleNon-binary
Relationship Status SingleMarriedSeparatedDivorcedWidow(er)
How would you like to receive appointment reminders?
Options Home Phone CallCell Phone CallText MessageEmail
Emergency Contact:
Primary Responsible Party
Same as Patient? YesNo
Who has referred you for this consultation?
Options DentistMedical DoctorLawyerInsurance Adjuster
Other:
We are pleased to work with you and your insurance carrier to obtain the maximum dental benefit for treatment
PRIMARY
Patient Relationship SelfSpouseChildOther
SECONDARY
Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your care. All information will be kept strictly confidential.
Frequency of Dental checkups Twice a yearOnce a yearOnly if a problem exists
Date of last visit
Is there any unfinished care to be completed with your dentist?
Options YesNo
Have you noticed any change in your bite or dental alignment recently?
What is your primary reason for your exam today?
Are you currently under a physician's care?
Are you currently taking any medcations?
List any medications or supplements you are currently taking:
Are you allergic to medications?
Are you pregnant?
Please check if you have had any of the following conditions:
Heart MurmurAnemia, Blood DisordersKidney DiseaseHerpes (Fever blisters)ArthritisHeart SurgeryHypertensionTuberculosisNervous/AnxiousSkin conditionsHeart Valve DefectRheumatic FeverCancerBronchitisEndocrine DisordersHepatitisAsthmaBone DisordersProlonged BleedingDiabetesEpilepsyFainting
Do you have any allergies? (Please Identify)
Is there any other condition or problem that you think we should know about?
I,
give written consent to Dr. Paul Major to divulge any diagnostics, records, correspondence and/or information relating to myself to:
I consent to the collection, use and disclosure of my personal information as set out above. By typing my name below, I am electronically signing and certifying that I am in understanding of all of the above statements
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