Step 1 of 8 12% PATIENT INFORMATIONFirst NameLast NamePatient Date of Birth SS#Gender Male Female Prefer Not to Respond Previous Name(s)Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail May we confirm your appointments and send you practice information via email? Yes No How did you hear of Dr. Norman?Existing Patients: click here to skip to the Authorization to Release Health Care Information Form EMPLOYMENT INFORMATIONEmployerWork Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone DENTAL INSURANCE INFORMATIONDental Insurance CompanyInsurance Company PhoneSubscriber's NameSubscriber's Date of Birth Group #SS# or Insurance ID# PERSONAL CONTACTSNearest Relative Not Living with You First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePerson Responsible for This Account First Last Responsible Person's PhonePerson to Contact in Case of Emergency First Last Emergency Contact Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Phone MEDICAL HISTORYFor the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential.1. Are you in good health?NoYes2. Has there been any change in your health in the past year?NoYes3. My last physical exam was on4. Are you now under the care of a physician?NoYesIf so for what condition?Name of PhysicianPhysician address5. Have you had any serious illness, operation or hospitalization within the past 5 years?NoYes6. Are you taking medicine(s) including non-prescription, homeopathic, or “natural” remedies including diet pills?NoYesIf so, please list7. Do you require pre-medication with antibiotics prior to dental appointments?NoYesDo you have or have you had any of the following diseases or problems?Damaged heart valves, artificial valves, heart murmurNoYesRheumatic FeverNoYesHeart trouble, heart attack, angina, high blood pressure, stroke, arteriosclerosis, or any other heart conditionNoYesChest pain upon exertion?NoYesShortness of breath after mild exercise?NoYesDo your ankles swell?NoYesDo you have a pacemaker?NoYesDo you have any pins/plates, artificial joints, or shunts placed?NoYesIf yes, when?If yes, Physician's Name and PhoneSeasonal allergies/ HivesNoYesSinus troubleNoYesAsthma or hay feverNoYesFainting spells or seizuresNoYesDiabetesNoYesHepatitis, jaundice or liver diseaseNoYesFrequent or recurring mouth soresNoYesThyroid problemsNoYesRespiratory problems, emphysema, bronchitisNoYesArthritis or painful, swollen joints including jaw joint (TMJ)NoYesStomach ulcer or hyperacidityNoYesKidney troubleNoYesTuberculosisNoYesPersistent cough or cough that produces bloodNoYesPersistent swollen neck glandsNoYesLow blood pressure or high blood pressureNoYesEpilepsy or neurological disorderNoYesCancerNoYesAny disease, drug or transplant operation that has depressed your immune systemNoYes9. Have you had abnormal bleeding?NoYesHave you ever required a blood transfusion?NoYes10. Do you have any blood disorder such as anemia?NoYes11. Have you ever had treatment for a tumor or growth?NoYesIf so, what type of treatment?12. Are you allergic to or have you had a reaction to:Local anestheticsNoYesPenicillin or antibioticsNoYesSulfa drugs or sulfideNoYesBarbiturates or sleeping pillsNoYesAspirinNoYesIodineNoYesCodeine or other narcoticsNoYesLatex or rubber productsNoYesOtherNoYes13. Have you had any serious trouble associated with previous dental treatment?NoYes14. Do you have any other condition or disease you think the doctor should know about?NoYes15. Are you taking or have you ever taken Bisphosphonates (Fosamax, Actonel, for osteoporosis, chemotherapy or multiple myeloma, etc.)?NoYes16. Are you wearing contact lenses?NoYes17. Are you wearing removable dental appliances?NoYes18. Do you wish to talk with the doctor privately about anything?NoYes19. Do you smoke? Have you smoked or chewed tobacco?NoYes20. Have you had treatment for drug or alcohol abuse?NoYes21. Do you eat (drink) grapefruit (juice)?NoYes22. Do you have or have you had any of the following symptoms:Headaches or migrainesNoYesFacial painNoYesNeck/Shoulder painNoYesTinnitus/Ringing in the earsNoYesWorn or cracked teethNoYesUnexplained loose teethNoYesSensitive or sore teethNoYesJaw PainNoYesNumbness in fingers or armNoYesClicking or popping in the jaw jointsNoYesLimited jaw movement or locking jawNoYes23. Have you had your tonsils removed?NoYesIf yes, at what age?24. Have you ever had a sleep study or a CPAP?NoYes25. Have you ever had BOTOX?NoYesWOMEN26. Are you pregnant or trying to become pregnant?NoYes27. Are you nursing?NoYes28. Are you taking birth control pills?NoYesPlease fully explain anything you answered “Yes” above CURRENT MEDICAL INFORMATIONPlease List All Doctors and PharmacyName and SpecialtyLocationPhone Number Add RemovePharmacy NamePharmacy PhonePlease list all Medications you are taking:(include Prescriptions, Over-the-Counter, Vitamins and Herbal Supplements)Drug NameDosage(how much)Frequency(how often)Taking For: Add RemovePlease List Any Allergic Reactions(Describe Reaction: did it make you sick, have a rash, difficulty breathing…)Drug NameReaction Add Remove AUTHORIZATION TO RELEASE HEALTH CARE INFORMATIONI request and authorize DreamSmile to release health care information of the patient named above to:Doctor's Name First Last Doctor's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This request and authorization applies to: All health care information Other I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV(AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV(AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.Signature of patient or patient’s authorized representativeDate Signed Relationship or status if signed by anyone other than patient (parent, legal guardian, personal representative, etc.)This authorization expires 90 days after the date it is signed. Thank you for taking the time to accurately complete this form. It will help us to provide you with our very best care.I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any member of the staff responsible for any errors or omissions that I have made in the completion of this form.
