Today's Date:			Sex:	Choose: Male Female
Title:	Choose: Mr. Ms. Dr.		Date of Birth:
First Name:			Age
Middle Initial:			Social Security Number:
Last Name:			Home Phone
Street:			Business Phone:
City:			Extension:
State:			Cell Phone
Zip Code			Email
Employer Name			Occupation

Dentist's Name:			How were you referred to our office?	Choose: Dentist Physician Insurance Company Phonebook Friend Colleague Other
Dentist Phone #:			Referral Name:
Physician's Name:			Marital Status:	Choose: Single Married Divorced Widowed Companion
Physician Phone #:			Name of Spouse:
Emergency Contact:			Emergency Phone #:

Who will be responsible for your account?	Choose: Self Spouse Parent Other		Social Security #:
Title:	Choose: Mr. Ms. Dr.		Home Phone
First Name:			Business Phone:
Middle Initial:			Extension:
Last Name:			Cell Phone
Street:			Email
City:			Employer Name
State:			Employer Phone #:
Zip Code			Relation to Patient:

Employer Name			Group ID #:
Employee Telephone #			Subscriber Name
Insurance Co. Name:			Subscriber Birthday
Insurance Co. Phone #:			Subscriber SSN / ID / Contract #:
Insurance Co. Address:			Relationship to Patient:

Employer Name			Group ID #:
Employee Telephone #			Subscriber Name
Insurance Co. Name:			Subscriber Birthday
Insurance Co. Phone #:			Subscriber SSN / ID / Contract #:
Insurance Co. Address:			Relationship to Patient:

In the following questions, indicate Yes or No, whichever applies. Indicate if you have or have ever had any of the diseases or problems indicated below. Your answers are for our records only and will be considered confidential .

Height
Weight
Are you in good health?	Choose: Yes No
Have there been any changes in your general health within the past year?	Choose: Yes No
My last physical examination was on
Are you now under the care of a physician?	Choose: Yes No
If so, what is the condition being treated?
Do you smoke?	Choose: Yes No
Have you had any serious illness or operation?	Choose: Yes No
If so, what was the illness or operation?
Have you been hospitalized or had a serious illness within the past five(5) years?	Choose: Yes No
If so, what was the operation?
HAVE YOU EVER SUFFERED FROM:
Alcoholism or drug addition?	Choose: Yes No
Rheumatic fever or rheumatic heart disease?	Choose: Yes No
Congenital heart lesions?	Choose: Yes No
Cardiovascular disease (e.g., Mitral Valve Prolapse, Heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)	Choose: Yes No
HAVE YOU EXPERIENCED ANY OF THE FOLLOWING:
Pain in the chest upon exertion?	Choose: Yes No
Shortness of breath after mild exercise?	Choose: Yes No
Swelling ankles?	Choose: Yes No
Shortness of breath when you lie down or do you require extra pillow when you sleep?	Choose: Yes No
DO YOU HAVE ANY OF THESE CONDITIONS:
A cardiac pacemaker or heart valve?	Choose: Yes No
Any hip or knee joint prosthesis?	Choose: Yes No
Allergies?	Choose: Yes No
Sinus trouble?	Choose: Yes No
Asthma or hay fever?	Choose: Yes No
Hives or a skin rash?	Choose: Yes No
Fainting spells or seizures?	Choose: Yes No
Diabetes?	Choose: Yes No
Urinate (pass water) more than six times a day?	Choose: Yes No
Thirsty much of the time?	Choose: Yes No
Frequent dry mouth?	Choose: Yes No
Hepatitis, jaundice or liver disease?	Choose: Yes No
Arthritis?	Choose: Yes No
Inflammatory rheumatism (painful swollen joints)?	Choose: Yes No
Stomach ulcers?	Choose: Yes No
Kidney trouble?	Choose: Yes No
Tuberculosis?	Choose: Yes No
A persistent cough or cough up blood?	Choose: Yes No
Low blood pressure?	Choose: Yes No
Venereal disease?	Choose: Yes No
AIDS or ARC?	Choose: Yes No
Abnormal bleeding associated with previous extractions, surgery, or trauma?	Choose: Yes No
Do you bruise easily?	Choose: Yes No
Ever required a blood transfusion?	Choose: Yes No
If so, explain the circumstances
Any blood disorders such as anemia?	Choose: Yes No
Surgery or x-ray treatment for a tumor, growth, or other condition of your head or neck?	Choose: Yes No
ARE YOU TAKING ANY OF THESE MEDICATIONS:
Any drugs or medications?	Choose: Yes No
If so, which drugs or medications?
Antibiotics or sulfa drugs?	Choose: Yes No
Anticoagulants (blood thinners)?	Choose: Yes No
Medicine for high blood pressure?	Choose: Yes No
Cortisone (Steroids)?	Choose: Yes No
Tranquilizers?	Choose: Yes No
Antihistamines ?	Choose: Yes No
Aspirin ?	Choose: Yes No
Insulin, Tolbutamide (Orinase) or similar drug ?	Choose: Yes No
Digitalis or drugs for heart trouble ?	Choose: Yes No
Nitroglycerin ?	Choose: Yes No
Oral contraceptives or other hormonal therapy ?	Choose: Yes No
Any other medication?	Choose: Yes No
If yes, please indicate which.
ARE YOU ALLERGIC OR HAVE AN ADVERSE REACTION TO:
Local anesthetics?	Choose: Yes No
Penicillin or other antibiotics?	Choose: Yes No
Sulfa drugs ?	Choose: Yes No
Are you allergic or have you reacted adversely to barbiturates, sedatives, sleeping pills?	Choose: Yes No
Aspirin?	Choose: Yes No
Iodine?	Choose: Yes No
Codeine or other narcotics?	Choose: Yes No
Jewelry, wrist watches or earrings?	Choose: Yes No
Other things?	Choose: Yes No
If yes, please indicate which.
Have you had any serious trouble associated with any previous dental treatment?	Choose: Yes No
If so, explain
OTHER:
Do you have any disease, condition, or problem not listed above that you think I should know about?	Choose: Yes No
If so, explain
Are you employed in any situations which exposes you regularly to x-rays or ionizing radiation?	Choose: Yes No
Are you wearing contact lenses?	Choose: Yes No
WOMEN's SECTION
Are you pregnant?	Choose: Yes No
Do you have any problems associated with your menstrual period?	Choose: Yes No
Are you nursing?	Choose: Yes No

I understand root canal treatment is a procedure to retain a tooth which may otherwise require extractions. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require retreatment, surgery, or even extraction.

I also understand that only the root canal treatment is to be performed at this office. The permanent (outside) restoration (filling, onlay, crown, etc.) will be done by my regular dentist.

I also acknowledge full responsibility for the payment of such services and agree to pay for them in full AT or BEFORE COMPLETION unless other specific arrangements are made with the office.

I authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. I also authorize release of any information necessary to process dental insurance.

This form needs to be signed upon arrival at the office.

Signature of Patient: ________________________________________

Date: ________________________________________

Signature of Dentist: _________________________________________

Date: _________________________________________