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Last, First MI (Preferred Name)
Birth Date: Phone (Home): ____
For your convenience, please provide your E-mail Address:_____________________ for appointment reminders.
Reason for this visit: ___________________________
Are you in good health? (Y) (N) If no, please explain:__________________________________________ Has there been any change in you general health this past year? ( Y ) ( N )
Have you ever or do you have any of the following? Please check all those that apply:
MEDICATIONS: Are you taking any of the following? Please list:
( ) Antibiotics? _______________
( ) Insulin or anti-diabetic drugs? _______________
( ) Anticoagulants (blood thinners)? ______________
( ) Aspirin or drugs such as Motrin, Aleve, Ibuprofen? _____
or other heart drug? _________________________
( ) High blood pressure medications? ________________
( ) Tranquilizers?____________________________
( ) Steroids (Cortisone, ect.)?__________________
Have you ever been advised to pre-medicate before dental procedures? (Y) (N)
Are you or have you ever taken Bisphosphonates: (FOSAMAX, ACTONEL OR BONIVA for osteoporosis, Aredia or Zometa for
various cancers, ect.)? (Y) (N)
Have you ever had any complications following dental treatment?
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain:
Are you now under the care of a physician?
If yes, please explain:
Name of Physician: _______________________________________________ Phone:
For Women Only:
Are you pregnant, or is there any chance you might be? (Y) (N) Are you nursing? (Y) (N) If you are using Oral Contraceptives,
it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral
contraceptives. Therefore you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other
medication is completed. Please consult with your physician for further guidance. Doctor notes:__________________________________________________________________________________________________
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my
health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian
Last, First MI (Preferred Name) Gender: Male
In the event of an emergency, whom should we contact? Please list someone NOT living with you.
Name___________________________________ Phone:__________________ Relationship to you__________
Name:__________________________________________________________________________ The following is for: the patient the person responsible for payment Employer Name
Name of Insured: ________________________________ Is the insured a patient?
Insured's Birth Date: _________________ ID# or SS#: _____________________ Group #:_________ Insured's Address:___________________________________________________________________________________
Insured's Employer Name and Address:__________________________________________________________________ ___________________________________________________________________ Patient's relationship to insured:
Insurance Plan Name and Address: ___________________________________________
How did you find out about Lighthouse Dental?
Location of our office Yellow Pages Insurance Carrier Friend/Relative Other :
Whom may we thank for referring you to our practice:_____________________________________
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Treat yourself to a comfortable and affordable beauty treatment that can brighten up your whole appearance and give you confidence. Words by Mo Shine With so many people going for whiter than In less than an hour, I felt that I had achieved white teeth today, I was feeling that I should exactly what I wanted – natural looking white, try and get back the nice smile I had many