ࡱ> Z\Yq` -bjbjqPqP 4N::0#  8 4 L *V!V!(~!~!~!~!~!~!K*M*M*M*M*M*M*$+h .q*&~!~!&&q*~!~!*(((&|~!~!K*(&K*(((~!J! 0z[L /'(*4*0*(.'.((h.#)~!H"("tL#g~!~!~!q*q*c(X~!~!~!*&&&&          Norcross Dental Center 5430 Jimmy Carter Blvd #125 Norcross, GA 30093 Tel: 770-441-7900 Thank You for Selecting Our Dental Team To help us meet all your healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us and we will be happy to help. Patient Information (Confidential) Patient Number____________________________ Name____________________________________________________________________________Date _____________________________________ Gender__________ Male / Female (Please Circle) Email Address _____________________________ Soc. Sec. #___________________________________________ Birth date________________ Home Phone ______________________________ Address_____________________________________________ City______________________ State_________________ Zip___________ Check Appropriate Box (Minor (Single (Married (Divorced (Widowed (Separated If Student, Name of School/College_______________________ City________________________ State _____ (Full Time (Part Time Patients or Parents Employeer________________________________________________________Work Phone_______________________________ Business Address_______________________________________ City______________________ State_________________ Zip___________ Spouse or Parents Name_________________________________ Employer___________________ Work Phone____________________________ Business Address_______________________________________ City______________________ State_________________ Zip___________ Whom May We Thank for Referring You? ________________________________________________________________________________________________ Person to Contact in Case of Emergency___________________________________________________________________________________________________ Responsible Party Name of Person Responsible for this Account________________________________________________Relationship to Patient_______________________ Addresss______________________________________________________________________________Home Phone ______________________________ Employer______________________________________________ Work Phone_____________________SS#______________________________________ Is this Person Currently a Patient in our Office? (Yes (No Insurance Information Name of Insured__________________________________________________________________________ Relationship to Patient______________________ Birth date______________________________________ Social Security #_____________________ Date Employed____________________________ Employer Address_______________________________________ City_______________________________ State_______________ Zip___________ Insurance Company_____________________________________ Group #____________________________ Policy/ID#________________________________ Ins. Co. Address_______________________________________ City_______________________________ State_______________ Zip___________ How Much is Your Deductible?___________________________ How Much Have You Used?____________ Max. Annual Benefit_______________________ Do You Have Any Additional Insurance? (Yes (No If Yes, Complete the Following Name of Insured__________________________________________________________________________ Relationship to Patient______________________ Birth date______________________________________ Social Security #_____________________ Date Employed____________________________ Employer Address_______________________________________ City_______________________________ State________________ Zip___________ Insurance Company_____________________________________ Group #____________________________ Policy/ID#______________________________ Ins. Co. Address_______________________________________ City_______________________________ State________________ Zip___________ How Much is Your Deductible?___________________________ How Much Have You Used?____________ Max. Annual Benefit_____________________ Patient Medical History Physician___________________________________________ Office Phone________________________ Date of Last Exam________________________ 1. Are you under medical treatment now? (Yes (No 2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? (Yes (No If yes please explain.______________________________________________________________________________________________________________________ 3. Are you taking any medications including non-prescription medicine? (Yes (No If yes, what medication(s) are you taking? ____________________________________________________________________________________________________ 4. Have you ever taken Phen/Fen/Redux? (Yes (No 5. Do you use tobacco? (Yes (No 6. Do you use controlled substances? (Yes (No 7. Do you have or have you had any of the following? High Blood Pressure (Yes (No Heart Disease (Yes (No Chest Pains (Yes (No Heart Attack (Yes (No Cardiac Pacemaker (Yes (No Easily Winded (Yes (No Rheumatic Fever (Yes (No Heart Murmur (Yes (No Stroke (Yes (No Swollen Ankles (Yes (No Angina (Yes (No Hay Fever/Allergies (Yes (No Fainting/Seizures (Yes (No Frequently Tired (Yes (No Tuberculosis (Yes (No Asthma (Yes (No Anemia (Yes (No Radiation Therapy (Yes (No Low Blood Pressure (Yes (No Emphysema (Yes (No Glaucoma (Yes (No Epilepsy/Convulsions(Yes (No Cancer (Yes (No Recent Weight Loss (Yes (No Leukemia (Yes (No Arthritis (Yes (No Liver Disease (Yes (No Diabetes (Yes (No Joint Replacement or Implant (Yes (No Heart Trouble (Yes (No Kidney Diseases (Yes (No Hepatitis/Jaundice (Yes (No Respiratory Problems (Yes (No AIDS or HIV Infection(Yes (No Sexually Transmitted Disease (Yes (No Mitral Valve Prolapse (Yes (No Thyroid Problem (Yes (No Stomach Troubles/Ulcers (Yes (No Other_____________(Yes (No 9. Are you allergic to or have you had reactions to the following? Local Anesthetics (e.g. Novocain) (Yes (No Penicillin or other Antibiotics (Yes (No Sulfa Drugs (Yes (No Barbiturates (Yes (No Sedatives (Yes (No Iodine (Yes (No Aspirin (Yes (No Any metals (e.g. nickel, mercury, etc.) (Yes (No Latex Rubber (Yes (No Other_____________________________ (Yes (No 10. Women Only: a. Are you pregnant or think you may be pregnant? (Yes (No b. Are you nursing? (Yes (No c. Are you taking oral contraceptives? (Yes (No Patient Dental History Name of Previous Dentist __________________________________________________________________ Date of Last Exam_________________________ Previous Dentists Location __________________________________________________________________ Date of Last Cleaning______________________ 1. Do your gums bleed while brushing or flossing? (Yes (No 2. Are your teeth sensitive to hot or cold liquids/foods? (Yes (No 3. Are your teeth sensitive to sweet or sour liquids/foods? (Yes (No 4. Do you feel pain to any of your teeth? (Yes (No 5. Do you have any sores or lumps in or near your mouth? (Yes (No 6. Have you had any head, neck or jaw injuries? (Yes (No 7. Have you ever experienced any of the following problems in your jaw? Clicking (Yes (No Pain (joint, ear, side of face) (Yes (No Difficulty in opening or closing (Yes (No Difficulty in chewing (Yes (No 8. Do you clench or grind your teeth? (Yes (No 9. Have you ever had any difficulty extractions in the past? (Yes (No 10. Have you ever had any prolonged bleeding following extractions?(Yes (No 11. Have you had any orthodontic treatment? (Yes (No Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and the records of any treatment or examination rendered to me and/or my child during the period of such Dental care to third party and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. X______________________________________________________________________Signature of patient (or parent if minor) Doctors Comment_______________________________________________________________________________ Signature _____________________________ Date ___________________________________       HYPERLINK "http://images.google.com/imgres?imgurl=www.hads.com/hads%2520inc%2520logo.gif&imgrefurl=http://www.hads.com/&h=213&w=215&sz=8&tbnid=0YK3ziMVgqUJ:&tbnh=100&tbnw=100&start=17&prev=/images%3Fq%3Ddental%2Blogo%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8%26sa%3DN"  INCLUDEPICTURE "http://images.google.com/images?q=tbn:0YK3ziMVgqUJ:www.hads.com/hads%2520inc%2520logo.gif" \* MERGEFORMATINET  Norcross Dental Center 770-441-7900 www.norcrossdentalcenter.com WXY5 6 X Z ]  9  7 u v | }   ! 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