Patient Forms - Mountain View Dentistry

Marital Status

Single

Maried

Are You in Good Health?

Yes

Are you under the care of a Physician?

Yes

List ALL Medications you are currently taking (Including non-prescription and Herbal)

Reason for Today's Visit

Date of Last Cleaning

Address1

Address 2

City

State

Zip

Phone

Area Code

Phone First 3

Phone Last 4

Please Check any Current or Past Medical Conditions

Abnormal Bleeding

Alcohol Abuse

Anemia

Angina Pectoris

Arthritis

Artificial Heart Valve

Artificial Joints

Asthma

Bisphosphonate Therapy

Bleeding Gums

Bruise or Bleed Easily

Cancer

Colitis

Congenital Heart Defect

Diabetes

Breathing Difficulty

Do You Snore

Drug Abuse

Emphysema

Fainting Spells

Frequent Headaches

Glaucoma

HIV+ or AIDS

Heart Attack

Hepatitis A, B C Other

Hemophelia

High Blood Pressure

Kidney Problems

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Pacemaker

Pain in Jaw Joint

Psychiatric Problems

Radiation Therapy

Reaction to Anesthetic

Rheumatic Fever

Seizures

Shingles

Sickle Cell Disease

Sinus Problems

Stroke

Thyroid Problems

Tuberculosis

Ulcers

Tooth Pain

Loose Teeth

Broken Teeth

Gum Disease

Bad Breath

Smoke

Hot/Cold Sensitivity

Chewing Sensitivity

For Women Only

Are You Nursing?

Are You Pregnant?

Allergies

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Jewelry

Latex

Metals

Penicillin

Tetracycline

Other

Patient Information and Insurance Data

Place of Employment

Address1

Address 2

City

State

Zip

Phone

Area Code

Phone First 3

Phone Last 4

Phone

Area Code

Phone First 3

Phone Last 4

Responsible Party

Name

Address1

Address 2

City

State

Zip

Home Phone

Area Code

Phone First 3

Phone Last 4

Work Phone

Area Code

Phone First 3

Phone Last 4

Dental Insurance Information

Name of Insured

Address1

Address 2

City

State

Zip

Ins. Co. Phone

Area Code

Phone First 3

Phone Last 4

Do You have Dental Insurance?

If Yes, Complete the information above in Dental Insurance Information

Yes

Do You have Medical Insurance?

If Yes, Complete the information below in Medical Insurance Information

Yes

Are You a Disabled Veteran?

Yes

If yes, Indicate the percentage of disability

Medical Insurance Information

Name of Insured

Address1

Address 2

City

State

Zip

Ins. Co. Phone

Area Code

Phone First 3

Phone Last 4

Payment is due when services are rendered. I understand that I am responsible for professional fees incurred on my behalf regardless of my insurance status. I understand that I am responsible for all costs incurred by Lanier Dental Group, Inc. DBA Mo

Patient Signature