Dentistry, tooth whitening, invisalign. Murphysboro, Il

General Information:

Patient's Name:
Social Security #:
Parent (if minor) :
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Birth Date:
Sex:		Male Female
Employer:
Marital Status:
Spouse's Name:
Date:
Reason for Appointment:

Health History:

Do you have or have you had: Yes or No (check specific condition)

1. Heart condition, murmur, bypass or mitral valve prolapse ..........................................	Yes No
2. Blood disorder or abnormal bleeding ..........................................................................	Yes No
3. Dizziness, fainting, shortness of breath .....................................................................	Yes No
4. Cancer, Tumor or cyst ................................................................................................	Yes No
5. Hepatitis, Jaundice or liver disorder............................................................................	Yes No
6. Stomach, digestive or intestinal disorder....................................................................	Yes No
7. Diabetes or family history of diabetes .......................................................................	Yes No
8. HIV+, aids, aids exposure, IV drug use .....................................................................	Yes No
9. Emotional, psychological, mental disorder .................................................................	Yes No
10. Sexually transmitted disease ..................................................................................	Yes No
11. Hospitalization within past 5 years .........................................................................	Yes No
12. Are you now under a doctor's care .........................................................................	Yes No
13. High or low blood pressure .....................................................................................	Yes No
14. Rheumatic fever, systerniclupus (sle)......................................................................	Yes No
15. Asthma, Emphysema, Bronchitis, TB........................................................................	Yes No
16. Radiation or Chemotherapy ....................................................................................	Yes No
17. Kidney, bladder or urinary tract disorder ................................................................	Yes No
18. Joint or organ surgery or transplant .......................................................................	Yes No
19. Neurological (nerve) disorder, seizures ..................................................................	Yes No
20. Thyroid condition, hormone imbalance ...................................................................	Yes No
21. Female: Are you pregnant?.....................................................................................	Yes No
22. Allergies (penicillin, food, etc)..................................................................................	Yes No
Explain any other information concerning your health:

Please list any medications you are currently taking:

Please list any medications taken with the last year (including diet):

Medical Doctor:
Phone #:

Insurance Information:

Insurance Company:
Insured Name:
DOB:
Insured Employer:
Insured Social Security #:

Multicoverage: More than one dental policy:

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Dental care to third party payers and/or other health practioners. 1 authorize and hereby request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the actual bill for services rendered. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. The information on this form is correct to the best of my knowledge. I give my consent to examination, medications and treatment.

Is there anything you would like to change about your smile?:

Have you ever thought about whitening your smile?:

Signature of patient or parent if minor:

Date: