Clovis Family Dentistry

Your information is safe

The benefits of a happy, healthy smile are immeasurable!
Our goal is to help you reach and maintain optimal oral health.

Please supply us with as much information as possible.
The better we communicate, the better we can care for you.

1. ABOUT YOU

Personal Information

Email Address *
Last Name *
First Name *
Middle Initial
Title
I prefer to be called
Sex *	Male Female
Birthdate *
Social Security Number *
Driver's License Number
Marital Status

Home Address

Address *
Apartment
Condo
City *
State *
Zip *

Telephone

Cell *
Home
Work
Extension
Direct Line

Employer

Name
Address
City
State
Zip
How long there?
Occupation

Other

Where & when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us
Name of Previous Dentist
Person Responsible for Account

2. SPOUSE INFORMATION

Personal Information

Name
Employer
Social Security Number
Birthdate

Telephone

Work
Extension
Direct Line

Emergency Contact

Name
Relation
Work Phone Number
Home Phone Number

3. INSURANCE

Dental Coverage

Yes No

Insurance Company

Company Name
Address
City
State
Zip
Phone Number

Insured Party

Group, Plan, Local or Policy Number
Name
Relation
Birthdate
Social Security Number
Employer Name
Employer Address
Employer City
Employer State
Employer Zip

4. MEDICAL HISTORY

Physician

Do you have a personal physician?	Yes No
Name
Phone Number
Last Visit Date

Physical Health

Your current physical health	Good Fair Poor
Are you currently under the care of a physician? Please explain	Yes No
Do you smoke or use tobacco in any other form?	Yes No
Have you had any metal rods, pins or implants?	Yes No
Are you taking prescription / over-the-counter drugs? Please list each one	Yes No
Have you ever taken Phen-Fen?(also known as Redux or Pandimin) If so, when?	Yes No
Have you taken or do you take Bisphosphonates now (e.g. Aredia, Actonel, Boniva, Fosamax, Zometa)	Yes No
For Women: Are you using a prescribed method of birth control?	Yes No
Are you pregnant? Number of weeks	Yes No
Are you nursing?	Yes No

Medical Problems

Have you ever had any of the following diseases or
medical problems

Abnormal Bleeding / Hemophilia	Yes No
AIDS	Yes No
Alcohol / Drug Abuse	Yes No
Anemia	Yes No
Arthritis	Yes No
Artificial Bones / Joints / Valves	Yes No
Asthma	Yes No
Blood Transfusion	Yes No
Cancer / Chemotherapy	Yes No
Colitis	Yes No
Congenital Heart Defect	Yes No
Diabetes	Yes No
Difficulty Breathing	Yes No
Emphysema	Yes No
Epilepsy	Yes No
Fainting Spells	Yes No
Frequent Headaches	Yes No
Glaucoma	Yes No
Hay Fever	Yes No
Heart Attack / Heart Surgery	Yes No
Heart Murmur	Yes No
Hepatitis	Yes No
Herpes / Fever Blisters	Yes No
High Blood Pressure	Yes No
HIV +	Yes No
Hospitalized for Any Reason	Yes No
Kidney Problems	Yes No
Liver Disease	Yes No
Low Blood Pressure	Yes No
Lupus	Yes No
Mitral Valve Prelapse	Yes No
Pacemaker	Yes No
Psychiatric Problems	Yes No
Radiation Treatment	Yes No
Rheumatic / Scarlet Fever	Yes No
Seizures	Yes No
Shingles	Yes No
Sickle Cell Disease / Traits	Yes No
Sinus Problems	Yes No
Stroke	Yes No
Thyroid Problems	Yes No
Tuberculosis (TB)	Yes No
Ulcers	Yes No
Venereal Disease	Yes No
Please list any serious medical condition(s) that you have ever had

Allergies

Are you allergic to any of the following?

Aspirin	Yes No
Erythromycin	Yes No
Penicillin	Yes No
Codeine	Yes No
Jewelry/Metals	Yes No
Tetracycline	Yes No
Dental Anesthetics	Yes No
Latex	Yes No
Other	Yes No
Please list any other drugs / materials that you are allergic to

5. DENTAL HISTORY

Dental History

Why are you coming to the dentist today?
Are you currently in pain?	Yes No
Do you require antibiotics before dental treatment?	Yes No
Your current dental health	Good Fair Poor
Have you ever had a serious / difficult problem associated with any previous dental work?	Yes No
Do you floss daily?	Yes No
Do you brush daily?	Yes No
Type of bristles on your toothbrush?	Hard Medium Soft
Have you ever had gum treatment?	Yes No
Do your gums ever bleed?	Yes No
Do your gums ever itch?	Yes No
Have you ever had periodontal disease?	Yes No
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?	Yes No
Are your teeth sensitive to heat, cold, or anything else?
Do you have any loose teeth?	Yes No
Do you still have wisdom teeth?	Yes No
Would you like fresher breath?	Yes No
Would you like whiter teeth?	Yes No
Are you happy with the way your smile looks?	Yes No
If not, what would you change?

Agreement

Payment is due in full at the time of treatment unless prior arrangements have been approved.
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment.
I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.
Please note that we require at least TWO business days to change your appointment. I acknowledge and agree to be charged for no show appointments.

I accept the terms of the agreement.

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