The following information is required to thoroughly diagnose any condition and to give the highest possible standards of professional services.
All information will be kept strictly confidential. 


 1. Have you ever had a serious illness or are you under the care of a physician now?    

3. Have you ever had any of the following: (Please check if applicable) 
  Yes No
Swelling of ankles, feet, hands     
Joint replacement / implants    
Skin problems/ Hives/ Rashes     
Thyroid Disease    
Heart Disease
Liver Disease
Kidney Disease
 4. Have you experienced any unusual or allergic reaction to any of the following:
  Yes  No
 Local Anesthetic    
 Sulfonamide (sulfa)    
 Any Metals    
    Yes No
5.  Are you currently on any blood thinners?  
6. Are you in a high-risk group or have you ever tested positive for:    
7. Do you or did you in the past receive intravenous or oral bisphosphonates (Fosamax, Actonel, Boniva)?
8. Have you ever been told that you need Antibiotics prior to Dental treatments?
 10. For Women: Yes No
   a) Are you pregnant?
   b) Are you nursing?
   c) Are you taking birth control pills?

  Referred by:


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    Yes   No
 Do your gums bleed while brushing or flossing?     
 Are your teeth sensitive to hot or cold liquids/foods?     
 Do you feel pain in any of your teeth?     
 Do you have sores or lumps in or near your mouth?     
 Have you had any head, neck or jaw injuries?     
 Have you ever experienced any of the following problems in your jaw:     
    Pain (joint, ear, side of face)      
    Difficulty/ discomfort in opening or closing    
    Difficulty/ discomfort in chewing     
 Do you have frequent headaches?     
 Do you clench or grind your teeth?      
 Do you bite your lips or cheeks frequently?    
 Have you noticed any loosening of your teeth? 
 Does food tend to get caught in between your teeth? 
 Have you ever had a periodontal treatment of your gums?
 Have you ever worn a nightguard or other appliance? 
 Have you ever had prolonged bleeding after extractions? 
 Have you ever had problems sleeping/breathing or sinus problems?
 Have you ever been told you snore?
 Have you ever been tested or diagnosed with sleep apnea? If so, when?

 Do you wear partials or dentures?
 Have you had orthodontic treatment? 

Office Financial and Insurance Policies 
As a courtesy to our patients, it is our policy to bill dental plans directly. However, patients are advised that they must be aware of the details, limits and time intervals of their insurance, as they are ultimately responsible for all charges incurred. 
      Are you aware of the limits and details of your dental benefits policy?     
Authorization and release 

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis, the records of examination & treatment rendered to me or my child to third party payors and/or health practitioner. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered to me or my dependents. 

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