Existing Patient Form - Santa Margarita Dentist

Patient Information

We appreciate the confidence you have placed with us to provide Dental Care to you. All information on this chart is necessary for our records and is strictly confidential.

Patient Name *

Last *

DOB *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone *

Email *

In case of emergency, contact (Please specify someone not living in your household)

Name *

Relationship to Patient *

Home Phone

Work Phone

Cell Phone

What is your current Occupation?

Who is your current Employer Name?

Referral information

Please let us know how you heard about us. *

Person’s Name *

Medical History List of Conditions

Please indicate which of the following you have had, or have at present:

COVID-19 *

Date of COVID-19 Test *

AIDS/HIV

Kidney Disease

Alcohol Addiction

Liver Disease

Arthritis, Rheumatism

Low Blood Pressure

Anemia

Mitral Valve Prolapse

Artificial Heart Valves

Nervous Problems

Artificial Joints

Neurological Disorders

Asthma

Pacemaker

Back Problems

Psychiatric Care

Bleeding Abnormally with Extractions or Surgery

Radiation Treatment

Blood Disease

Recreational Drugs

Breast Augmentation

Respiratory Disease

Cancer

Smoke Cigarettes

Date of Cancer Diagnosed: *

Type of Cancer: *

Chemotherapy

Rheumatic Fever

Chemical Dependency

Scarlet Fever

Circulatory Problems

Shortness of Breath

Congenital Heart Lesions

Sinus Trouble

Cortisone Treatments

Skin Rash

Cough, persistent or bloody

Special Diet

Stroke

Diabetes

Emphysema

Swollen Feet or Ankles

Epilepsy

Swollen Neck Glands

Fainting/Dizziness

Smokeless Tobacco

Headaches

Tonsillitis

Heart Murmur

Tuberculosis

Heart (surgery, disease, attack)

Tumor/Growth on Neck

Hemophilia

Thyroid Problems

Hepatitis

Weight Loss Unexplained

Herpes/Cold Sores

Do you wear contact lenses?

High Blood Pressure

Do you take aspirin daily?

Jaundice

Blood Thinners

Do you currently have or have you had any disease, conditions, or problems not listed?

If Yes, Please List *

Have you been under the care of a medical doctor during the past two years? *

If Yes, For What? *

Physician’s Name *

Phone Number *

Have you ever taken any bisphosphonates for osteoporosis such as Fosomax, Actonel, Boniva, Prolia, or others?

if yes, which one and for how long?

Have you been a patient in the hospital during the past five years?

What was the date of your last physical?

Do you use more than 2 pillows to sleep?

Have you lost or gained more than 10 pounds in the past year?

WOMEN

Are you pregnant?

Could you be pregnant?

Expected delivery date? (copy)

Are you nursing?

Do you use birth control?

Allergies

Aspirin
Barbiturates (Sleeping Pills)
Codeine
Lodine
Latex
Penicillin
Sulfa
Local anesthesia
NO ALLERGIES
OTHER

Other Allergies

Are you taking any Medicines? *

List any medications you are currently taking (including aspirin and over the counter herbals), including dosages *

What are some of your hobbies/interests?

Do you have any important upcoming events in your life?

Who is your favorite sports team?

Pharmacy Name

Phone

Insurance information

Do you have Dental Insurance ?

Policy Holder Information

Subscriber's Name

Last

DOB

Dependent's Name

Relationship to Patient

Dental Insurance Company

Dental Insurance Phone Number *

Insurance ID Number OR Social Security Number *

Group Number

Assignment and Release

Name

Relationship to Patient

Date

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist of any changes in my health or medication(s).

Date *