Patient Information

Please fill out these forms so we can expedite your first visit:

First Name:

Middle Initial:

Last Name:

Preferred Name:

If Child, Parent's Name:

Street Address:

City:

State:

Zip:

Home Phone:

Work:

Cell:

Preferred Method of Contact:EmailTextPhone

Date of Birth:

Social Security #:

E-Mail:

Occupation:

Sex:MaleFemale

Marital Status:SingleMarriedDivorcedWidowed

Emergency Contact Name:

Number:

Whom may we thank for referring you?

Preferred Pharmacy:

Pharmacy Phone #:

What brings you in to see us today?

Please add anything you feel important for the doctor to know:

Dental Insurance Information:

Insured's Name:

Relationship to Patient:

Insured's ID #:

Insured's Date of Birth:

Employer of Insured:

Group #:

Insurance Company:

Insurance Phone #:

Signature:

Medical History

Parkway Oral Surgery

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Heath 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?

YesNo

If yes

Have you ever been hospitalized or had a major operation?

YesNo

If yes

Have you ever had a serious head or neck injury?

YesNo

If yes

Are you taking any medications, pills, or drugs?

YesNo

If yes

Do you take, or have you taken, Fhen-Fen or Redux?

YesNo

If yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo

If yes

Are you on a special diet?

YesNo

Do you use tobacco?

YesNo

Women: Are you...

Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

Are you allergic to any of the following?

AspirinEnicillinCodeineAcrylicMetalAtexSulfa DrugsLocal Anesthetics

Do you use controlled substances?

YesNo

If yes

Other?

Other

If yes

Do you have, or have had, any of the following?

AIDS/HIV Positive

YesNo

Cortisone Medicine

YesNo

Hemophilia

YesNo

Radiation Treatments

YesNo

Alzheimer's Disease

YesNo

Diabetes

YesNo

Hepatitis A

YesNo

Recent Weight Loss

YesNo

Anaphylaxis

YesNo

Drug Addiction

YesNo

Hepatitis B or C

YesNo

Renal Dialysis

YesNo

Anemia

YesNo

Easily Winded

YesNo

Herpes

YesNo

Rheumatic Fever

YesNo;

Angina

YesNo

Emphysema

YesNo

High Blood Pressure

YesNo

Rheumatism

YesNo

ArthritisiGout

YesNo

Epilepsy or Seizures

YesNo

High Cholesterol

YesNo

Scarlet Fever

YesNo

Artificial Heart Valve

YesNo

Excessive Bleeding

YesNo

Hives or Rash

YesNo

Shingles

YesNo

Artificial Joint

YesNo

Excessive Thirst

YesNo

Hypoglycemia

YesNo

Sickle Cell Disease

YesNo

Asthma

YesNo

Fainting Spells/Dizziness

YesNo

Irregular Heartbeat

YesNo

Sinus Trouble

YesNo

Blood Disease

YesNo

Frequent Cough

YesNo

Kidney Problems

YesNo

Spina Bifida

YesNo

Blood Transfusion

YesNo

Frequent Diarrhea

YesNo

Leukemia

YesNo

Stomad-VIntestinal Disease

YesNo

Breathing Problems

YesNo

Frequent Headaches

YesNo

Liver Disease

YesNo

Stroke

YesNo

Bruise Easily

YesNo

Genital Herpes

YesNo

Low Blood Pressure

YesNo

Swelling of Limbs

YesNo

Cancer

YesNo

Glaucoma

YesNo

Lung Disease

YesNo

Thyroid Disease

YesNo

Chemotherapy

YesNo

Hay Fever

YesNo

Mitre! Valve Prolapse

YesNo

Tonsillitis

YesNo

Chest Pains

YesNo

Heart Attack/Failure

YesNo

Osteoporosis

YesNo

Tuberculosis

YesNo

Cold Sores/Fever Blisters

YesNo

Heart Murmur

YesNo

Pain in Jaw Joints

YesNo

Tumors or Growths

YesNo

Congenital Heart Disorder

YesNo

Heart Pacemaker

YesNo

Farathyroid Disease

YesNo

Ulcers

YesNo

Convulsions

YesNo

Heart Trouble/Disease

YesNo

Psychiatric Care

YesNo

Venereal Disease

YesNo

Yellow Jaundice

YesNo

Have you ever had any serious illness not listed

YesNo

If yes

Name:

Email:

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:

Patient Forms

Your first visit to Parkway Oral Surgery & Dental Implant Center establishes a vital foundation for our relationship with you. You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

ONLINE PATIENT FORMS

Patient Registration

You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. On your first visit to our office, we will have your completed form available for your signature. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

Patient Forms

ONLINE PATIENT FORMS

Patient Registration

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