Bay area endo info

BAY AREA ENDODONTICS, LLP
1550 S. HIGHLAND AVENUE, SUITE A • CLEARWATER, FL 33756 • TELEPHONE (727) 443-3231 PLEASE PRINT THE FOLLOWING INFORMATION
Patient ________________________________________________________________________________Dr.
Home Address __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Other Address __________________________________________________________________________________________________ Employed by _______________________________________________ Occupation ______________________ Dept. ___________ Name of General Dentist _____________________________ Referred by (if different than general dentist): _____________________ Name of Spouse, Parent / Guardian _________________________________________ __________ S.S. No. _____________________ Employed by _______________________________________ Occupation ___________________ Bus. Phone # ________________ Name of Medical Physician _________________________________________________________ Phone ( _____ ) ______________ Cash ____ Check ____ Credit Card ____ Dental Insurance ____ Dental Insurance Information: Subscriber's Name ___________________________ Birthdate __________ S.S. No. ______________ Insurance Company _____________________________ Policy No. __________ Group No. ___________ Phone ( _____ ) _____________ Insurance Address _______________________________________________________________________________________________ Secondary Insurance: Subscriber's Name _________________________________ Birthdate __________ S.S. No. ______________ Insurance Company _________________________ Policy No. _____________ Group No. ____________ Phone ( ____ ) __________ Insurance Address ___________________________________________________________________________________________ In case of Emergency Notify ___________________________________ Relationship _____________ Phone _______________ PLEASE ANSWER ALL QUESTIONS
1. Are you now or have you been under the care of a physician in the past 2 years?.
2. Have you ever been hospitalized or had any operations?.
4. Do you need to premedicate with antibiotics before dental treatment for medical reasons?.
5. Have you experienced any unfavorable reaction to previous dental treatment?.
6. Please list any medications you are currently taking: __________________________________________________ 7. Birth Control Pill users must use additional methods while taking antibiotics and for 72 hours afterward.
8. Check any you have had or currently have: ___ PENICILLIN OR OTHER ANTIBIOTICS (if yes, describe) ________________________________________________________________ XYLOCAINE OR OTHER DENTAL ANESTHETICS (if yes, describe) _______________________________________________________ CODEINE OR OTHER PAIN MEDICATION (if yes, describe) ___________________________________________________________ Date ______________ Signature __________________________________________________________________________________

Source: http://www.bayareaendo.net/editor/assets/041E6CA2-845F-4607-A8B5-C29832001DF7.pdf