Your present dentist ________________________________city ___________________________ how long

DATE _____________________

Patient Name_______________________________________________________________________________________
First M. Initial Last Name you like to be called
Birthdate _____/_____/_____ Age______ □ Male □ Female
Mailing Address _______________________________________ Cell Phone (________)___________________________
City, State, Zip ________________________________________ Home Phone (________)__________________________
Father’s Name ________________________________________ Father’s Employer _______________________________
Father’s Occupation ___________________________________ Business Phone (________)________________________
Mother’s Name ________________________________________ Mother’s Employer _______________________________
Mother’s Occupation ___________________________________ Business Phone (________)________________________
Whom may we thank for referring you? _____________________________________________________________________
In case of emergency, a local relative or friend to be notified (not living at same address).
Name _______________________________________________ Relationship to Patient ____________________________
Address _____________________________________________ Phone (________)_______________________________
Primary Insurance Co. __________________________________ Patient's Relationship to Subscriber:
Mailing Address _______________________________________ Insurance Co. Phone # (________)__________________ City, State, Zip ________________________________________ Insurance Group # _______________________________ Subscriber's Name _____________________________________ Union Local # ___________________________________ Subscriber's ID# _______________________________________ Birthdate _____/_____/_____ I give my consent to Michaud Periodontics and Dental Implants to release any of my dental records to my insurance companies, physician, general dentist or any other doctor related to my care. I authorize release of any information to my medical and/or dental insurance companies relating to services with Michaud Periodontics and Dental Implants. I authorize insurance payments to be directly made to Michaud Periodontics and Dental Implants.
Both the above and the medical history on the reverse side are accurate

Date ______/_______/_______
Signature (if patient is a minor, then parent or guardian) Your present dentist __________________________________ City ________________________ How long? ____________ Last dental cleaning ____________________________________________ Have you ever had previous periodontal (gum treatment)? □Yes □ No When and by whom _____________________________________________________________________________
Why are you here today? ________________________________________________________________________________
Name of physician _________________________________ City __________________________ Phone ________________
Check if you are allergic or have reacted adversely to any of the following?
□ Dental anesthetics (Novacaine, etc.) □ Penicillin/Amoxicillin □ Barbiturates, sedatives, or sleeping pills
□ Valium, Halcion, or other Benzodiazapines □ Codeine □ Percodan / Percocet
□ Demerol □ Vicodin □ Keflex
□ Ibuprofen □ Aspirin □ Tylenol
□ Tetracycline □ Erythromycin □ Sulfa drugs
□ Sulfite preservatives □ Latex □ Sutures/stitches
□ Cipro/Clinda □ Iodine □ Other __________________________
Have you ever used intravenous (injected) bisphosphonates (Zometa, Aredia, or Boniva)?_____________________________
Are you now using or ever used oral (pill) bisphosphonates (Fosamax, Actonel, or Boniva)?____________________________
Do you currently require an antibiotic premedication for dental appointments? _______________________________________
Are you on any special diet? _____________________________________________________________________________
Do you currently smoke? Y / N Amount? ____________ Have you ever smoked? Y / N If yes, details: _______________
Smokeless tobacco / snuff? Y / N
Have you ever had extensive radiation therapy? ______________________________________________________________
List all medications you are now taking (Rx, over the counter, or natural/herb supplements)____________________________
Do you have or have you ever had any of the following diseases or problems? PLEASE CHECK IF YES:
□ Rheumatic fever □ Rheumatic heart disease □ Pacemaker □ Heart murmur
□ Heart trouble □ High blood pressure □ Artificial heart valves □ Artificial joints
□ Prostate disorders □ Kidney disease □ Liver disease □ Hepatitis A / B / C
□ AIDS / HIV positive □ Asthma □ Tuberculosis □ Respiratory (Lung) disease
□ Arthritis □ Seizures or epilepsy □ Alcoholism □ Thyroid or parathyroid disorders
□ Drug addiction □ Diabetes □ Stomach ulcers □ Osteoporosis/Osteopenia
□ Glaucoma □ Hemophilia □ Bleeding disorders □ Sleep disorder
□ Sleep Apnea □ Cancer □ Anemia □ Anxiety
□ Depression □ Bi-Polar □ Schizophrenia
Please describe any other information you feel we should be aware of relative to your health (Surgical/Anesthesia History):
Are you pregnant? □ Yes □ No If yes, expected delivery date _____________________
Do you think you might be pregnant? □ Yes □ No
Are you breast-feeding? □ Yes □ No
Are you taking female hormones (oral contraceptives, etc.)? □ Yes □ No

Both the above and on the reverse side are accurate.

Date ______/_______/_______
Signature (if patient is a minor, then parent or guardian)


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