Order Number MEDICAL HISTORY Are you currently under a physicians care (other than routine checkups) * Yes No If yes, please explain Have you been hospitalized in the past year * Yes No If yes, please explain Are you currently taking blood thinners (including baby aspirin)? * Yes No Name of medication Do you need to be pre-medicated with Antibiotic before dental procedure? (ex. heart problems, joint replacement) * Yes No If yes, name of premed Dosage Please list all medications you are currently taking Have you ever had any of the following medical problems or diseases? Heart Murmur * Yes No Rheumatic Fever * Yes No Mitral Valve Prolapse * Yes No Heart Problems * Yes No If Yes, Explain Joint Replacement * Yes No If Yes, Explain Pacemaker * Yes No High Blood Pressure * Yes No Low Blood Pressure * Yes No Epilepsy/Seizures/Fainting Spells * Yes No Drug Abuse * Yes No Alcohol Abuse * Yes No Suppressed Immune System * Yes No Tobacco User * Yes No Hemophilia/Abnormal Bleeding * Yes No HIV/Aids * Yes No Tuberculosis (TB) * Yes No Cancer * Yes No Type Chemo/Radiation Chemo Radiation Date of last treatment Hepatitis * Yes No Type Diabetes * Yes No Insulin * Yes No Are you currently pregnant? * Yes No Are you allergic to any of the following drugs: Penicillin/Amoxicillin * Yes No Aspirin * Yes No Tetracycline * Yes No Biaxin * Yes No Dental Anesthetics * Yes No Erythromycin * Yes No Sulfa * Yes No Fluoride * Yes No Codeine * Yes No Latex * Yes No Are you allergic to any other drugs: * Yes No If yes, please list: PATIENT INFORMATION *From previous form. Please review all information on this page, make any necessary changes and then Submit and Continue. First Name Last Name Date of Birth Gender Address Apartment Number City State Zip Home Phone Cell Phone Email Address You prefer to receive calls at: Status Patient Employer Occupation Full Time Student? School? Referred by DENTAL INSURANCE AND BILLING *From previous form Dental Insurance Co. Group # Employer (or former if retired) Policyholder/Subscriber Name Date of Birth SSN # ID # BILLING INFORMATION *From previous form Name of person responsible for account Relationship to patient Phone Address Apartment Number City State Zip Name of Employer Work Phone CERTIFICATION & ASSIGNMENT To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Farmington Family Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Electronic Signature Aggreement * I ACCEPT. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. Digital Signature * Today's Date * PLEASE ENSURE ALL INFORMATION IS CORRECT. WHEN YOU CLICK SUBMIT AND CONTINUE, THE PREVIOUS 3 FORMS WILL BE SENT TO THE OFFICE AND YOU WILL BE FORWARDED TO 2 MORE FORMS BEFORE YOUR PROCESS IS COMPLETE. YOU WILL NOT BE ABLE TO MAKE ANY FURTHER CHANGES TO THE INFORMATION ABOVE.