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Microsoft word - do not print-health history.doc

S. BRETT DELAWTER, DDS
1025 N. Brand Blvd., #210
Glendale, CA. 91202
(818) 242-1708
NAME:_____________________________________________________________________ ADDRESS:__________________________________________________________________ CITY:_________________________________STATE:___________ZIP:________________ OCCUPATION_________________________ EMPLOYER ___________________________ BIRTHDATE:__________________________ S.S. NUMBER_________________________ TELEPHONE: Home________________Business________________Cell________________ EMAIL______________________________________________________________________ EMERGENCY CONTACT AND NUMBER:_______________________________________ INSURANCE INFORMATION
PRIMARY INSURANCE CO. NAME & ADDRESS: ________________________________________
POLICY/ GROUP NUMBER: _____________________________________________________________
EMPLOYER NAME:________________________________ ADDRESS:__________________________
EMPLOYEE NAME:____________________________________________________________________
EMPLOYEE BIRTHDATE:___________________EMPLOYEE S.S. NUMBER: ___________________
SECONDARY INSURANCE CO. NAME & ADDRESS: _____________________________________
POLICY/GROUP NUMBER: _____________________________________________________________
EMPLOYER NAME:_________________________________ ADDRESS _________________________
EMPLOYEE NAME:____________________________________________________________________
EMPLOYEE BIRTHDATE:___________________EMPLOYEE S.S. NUMBER: ___________________
AUTHORIZATION
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I
understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the
doctor to release all information necessary to secure the payment of benefits.
SIGNATURE:____________________________________________DATE:_________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SPOUSE / PARENT NAME:______________________________________________________________ ADDRESS:____________________________________________________________________________ EMPLOYER:___________________________________________________________________________ BIRTHDATE:___________________________________S.S. NUMBER___________________________ TELEPHONE: Home____________________Business___________________Cell___________________ How did you hear about us? _______________________________________________________________ Why did you leave your last dentist? ________________________________________________________________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MEDICAL HISTORY AND INFORMATION
Have you had:
Are you Allergic to:
Are you currently under the care of a physician?
Yes ( ) No ( ) If yes, Doctor Name__________________ If yes, please explain:______________________________ ________________________________________________ High Blood Pressure Please list all current medications (include dosage and
condition you are taking it for): ______________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Have you ever had an adverse reaction to an anesthetic?
Alcoholism Yes ( ) No ( ) If yes, what?________________________ Do you use tobacco products? Do you require Antibiotic pre-medication for dental work?
If yes, what?___________________________ Yes ( ) No ( ) If yes, what?_________________________ Female Patients:
Yes ( ) No ( ) Have you taken the medication
Bisphosphonate as treatment for osteoporosis?
Yes ( ) No ( ) Are you taking Birth Control Medication? (Such as Actonel, Boniva, Didronel, Fosamax, Reclast, etc) I hereby authorize the dental office to administer such medications and perform such diagnosis and therapeutic Procedures as may be necessary for proper dental care. The information on this page and the medical history are correct to the best of my knowledge. I certify to the above statements regarding my medical condition. Payment for all treatment and services rendered are my responsibility. Patient Signature
If patient or child is under 18 or requires a guardian: ______________________________________________________________________________________ Parent/Guardian Signature

______________________________________________________________________________________
Reviewed by

Source: http://theglendaledentist.com/wp-content/uploads/2012/11/Health-History.pdf

Parte iii

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