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Mr.|Mrs.|Dr.|Rev. _____________________________________________________________________________________________________ Address _______________________________________________________________________________________________________________ Phone ________________________________________________________________________________________________________________ Date of Birth ____________________________________ SS# __________________________________________ Gender Male|Female Email _________________________________________________________________________________________________________________ Employer ____________________________________________ Occupation/Position ____________________________________________ How did you find us? O Dentist __________________________________ O Physician ________________________________________ O Friend ___________________________ O Yellow Pages O Website _______________________________ General Dentist _______________________________________________________________________________________________________ Responsible Party_______________________________________________________/______________________________________________ Emergency Contact___________________________________________________/_______________________________________________ Phone ________________________________________________________________________________________________________________ Have you previously been a patient of Shenandoah Valley Implant Institute? Yes|No If yes, which doctor? Dr. Steve|Dr. Vic|Dr. Dickson Insurance Information
Do you have DENTAL insurance? Yes|No
Insurance Co. _________________________________________________________________________________________________________ Employer ______________________________________________________________________________________________________________ Group # _______________________________________________________________________________________________________________ Subscriber______________________________________________________________________ Self|Spouse|Parent|Other Name Subscriber's SS#____________________________________________________ Subscriber's DOB___________________________________ Please give your dental insurance card to the receptionist. Thank you! Shenandoah Valley Implant Institute, LLC
Patient Name ____________________________________________________________ Date of Birth _______________________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?.OYes ONo If yes, please explain ___________________________________________Have you ever been hospitalized or had a major operation?.OYes ONo If yes, please explain ___________________________________________Have you ever had a serious head or neck injury?.OYes ONo If yes, please explain ___________________________________________Are you taking any medication, pills or drugs?.OYes ONo If yes, please explain ___________________________________________Do you take, or have you taken, Pehn-Fen or Redux?.OYes ONo If yes, please explain ___________________________________________Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphates?.OYes ONo If yes, please explain ___________________________________________Are you on a special diet?.OYes ONo If yes, please explain ___________________________________________Do you use tobacco?.OYes ONo If yes, please explain ________________________________________________________ Women: Are you pregnant/trying to get pregnant? OYes ONo Taking oral contraceptives? OYes ONo Nursing? OYes ONo Are you Allergic to any of the following? OAspirin OPenicillin OCodeine OLocal Anesthetics OAcrylic OLatex OSulfa drugs OOther If yes, please explain ________________________________________________________ Do you have, or have you had any of the following?AIDS/HIV Positive Have you ever had any serious illness no listed above? OYes ONo Your greatest medical risk? _________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ Comments ______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT OR GUARDIAN_____________________________________________________________________ Date ______________________

Source: http://www.implantdocs.us/docs/new_patient_form.pdf