Patient Information s3

MEDICAL HISTORY PATIENT INFORMATION Dr.___Rev.____Mr.___Mrs. ___Ms. ___ Are You In Good Health? YES NO

Name______Have You Been Treated By a Physician during the Past Two Years YES NO Date of Birth Day______Month______Year______Are You Taking Any Medication? YES NO Home Address______Please List ______City______Postal Code______Are You Sensitive or Allergic To: Phone ( ) ______Cell( )______PENICILLIN YES NO Occupation ______CODEINE YES NO Employer ______LOCAL ANESTHETIC (FREEZING) YES NO Business Address ______Are You Sensitive or Allergic To Any Other Medications? Business Phone ( ) ______YES NO

Marital Status ______Have You Ever Had An Unfavourable Reaction Following Dental Treatment? YES NO Name of Spouse/Parent ______Have You Ever Had Excessive Bleeding Requiring Special Telephone#______treatment? YES NO

Do you have insurance? Yes No Do You Suffer From TMJ Problems YES NO (Jaw Joint) Circle Any Of The Following Which You Have Had OR Insurance Information for SELF Have Been Diagnosed As Having: Name of Insurance Company ______Anemia Epilepsy Congestive Heart Failure Policy # ______Certificate ID #______Stroke Heart trouble Rheumatic Fever Complete if you have secondary insurance Asthma Hepatitis Heart Murmur Name of Insurance Company ______AIDS Tuberculosis High Blood Pressure Cancer Diabetes Kidney Disease Policy #______Certificate ID #______Arthritis Neuralgia Sinus Problems Angina Jaundice Psychiatric treatment Policy Holder ______Thyroid Depression Prosthetic Heart Valve Mitral Valve Prolapse Hip Replacement Employer ______Pacemaker Knee Replacement Date of Birth Day_____Month______Year______Have You Had any Other Serious Illness Not Listed Who Referred You To Our Office?______Above? ______

Dentist ______Female Patients: Are You Pregnant YES NO

Family Doctor ______Which Month? ______

Doctor's Phone ( ) ______

CONSENT FOR ROOT CANAL PROCEDURE, LOCAL ANESTHETIC AND X-RAYS I, the undersigned being the patient, or guardian of the above named minor patient, consent to the performing of whatever procedure may be mutually decided upon to be necessary or advisable in the opinion of the Doctor. I also give my consent to contact my doctor(s) and or my dentist(s) for clarification of the above information or any information needed to render treatment. I also understand that upon completion of root canal therapy in the office I must return to my general dentist for the permanent restoration of the tooth. There is a charge of $100.00 for the consultation with the Doctor, which is due after your appointment.

Signature______Date______YOU MUST RETURN TO YOUR OWN DENTIST TO HAVE THE TOOTH FILLED OR A CROWN PLACED. FAILING TO DO SO MAY RESULT IN THE LOSS OF THE TOOTH. THANK YOU.