Southerndentalgroup.net

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. We are
looking forward to working with you on maintaining your health.
Patient Information
Patient_____________________________________________________Sex: M F DOB:___________________ Marital: S M W D Address____________________________________ _______City _______________ State ____________ Zip __________________ Home Phone _______________________Cell _____________________SS # ___________________Pharmacy _________________ Email ______________________________________Occupation/Employer _____________________Work Phone_______________ Who should be notified in case of an emergency?____________________________________ # ______________________________ How would you prefer for us to contact you? Home phone Work phone Cell phone Whom may we thank for referring you to our office? _________________________________________________________________ Primary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB ______________SS#___________________ Address_____________________________________________________________________________________________________ Employer _______________________________ _Insurance Co.________________________________________________________ Secondary Dental Insurance
Insured’s Name___________________________Relationship ________________ DOB _________ _SS#______________________ Address_____________________________________________________________________________________________________ Employer _______________________________ Insurance Co._________________________________________________________ Medical History
Former Dentist___________________________ Address_________________________________ Phone # _____________________
Physician’s Name___________________________________ Phone # ____________________ Last Visit ______________________
Are you currently under a physician’s care? ________ _If yes, describe __________________________________________________
Have you ever been hospitalized, had major operations or serious illness? ________________________________________________
Have you ever had a blood transfusion? _________ If yes, give approximate dates _________________________________________
Women: Do you suspect that you are pregnant? ______Are you nursing? _______ Do you take birth control pills?________________
Do you use any tobacco products? _______What kind? ________________ How long? ________How much per day?_____________
Please check if you currently have, or have ever had any of the following:
__ Mitral Valve Prolapse
Are you taking or have you ever taken bone replacement medications? (Ex. Boniva, Fosamax, Actonel, Zometa, etc.) _____________
____________________________________________________________________________________________________________
List any medications you are currently taking_______________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List any drug allergies__________________________________________________________________________________________
- I authorize the release of my dental records and medical information to Dr. Michael E. Pope.
- I consent to treatment considered necessary by the dentist or qualified designate.
Signature______________________________________________________________ Date ________________________________

Source: http://www.southerndentalgroup.net/docs/patientwelcome.pdf