Smiles By Soileau Form

Personal Info

Name

Social Securty #

Birth Date

Employer

Name of Spouse

Address

Street Address City State / Province / Region ZIP / Postal Code

Who may we thank for referring you to our office?

Contact Info

Cell #

Home #

Work #

Email

Emergency Contact: Name

Emergency Contact: Number

Insurance Coverage

Insurance Company Name

Policy Number

Name of covered employee

Social Security of cover employee

AUTHORIZATION & release

I authorize Dr. Soileau or his employees to release any information concerning my dental treatment or my child's dental treatment to third party payers and/or other medical/dental offices.

Signature*

Medical History

Please complete all sections

Name

Date

Medications: (Including "over the counter" i.e. aspirin, vitamins)

Allergies

Penicillin
Codeine
Latex
Other

Other*

Heart Problems

What is your Usual Blood Pressure?*

Do you need to take antibiotics before dental appointment?

Yes
No

Bleeding

Do you bleed easy?

Yes
No

Are you on blood thinners?

Yes
No

Do you have Hepatitis?

Yes
No

Diabetes

Do you have Diabetes?

Yes
No

If yes, is your diabetes under control?*

Yes
No

Breathing Problems

Do you have any breathing problems?

Do you need help sleeping?

Yes
No

If so, what do you do?*

Were your tonsils removed?

Yes
No

Do you wake up tired?

Yes
No

Do you use a CPAP for sleeping?

Yes
No

How often do you wake up at night?

Yes
No

Do you have sleep apnea?

Yes
No

When were you diagnosed?*

Would you like information on an FDA approved treatment for sleep apnea?*

Yes
No

FEMALES

Are you pregnant or breast feeding?

Yes
No

If so, when is your due date?*

Cancer

Do you (or have you ever had) cancer?

Yes
No

When Diagnosed? What kind?*

How are you or were you being treated?

Surgery
Chemo
Radiation

**Some cancer treatments alter the oral environment; Pre-cancer symptoms may first appear in oral tissue**

General Questions

Do you smoke?

Yes
No

How often / how many packs per day?*

Would you be interested in Sedation for particular procedures?

Yes
No

Any JOINT Replacements?

Yes
No

Surgery Date

Surgeon

Nerves/Muscles/Bones

Can you reclined back comfortably in the dental chair?

Yes
No

Do you have a Neuromuscular Disorder?

Yes
No

If so, what is it?*

Immune System

Primary Physician

Name Location

Specialist

Name Location

Consent for Treatment

By state law we required to make an attempt to inform patents of possible complications, even though rare, which could result from anesthesia, local and/or sedation.

Allergic reactions which could require hospitalization.
Cardiac arrest, which could result in brain damage or even death.

It must be understood that these complications are extremely rare and every possible precaution will be taken to prevent their occurrence as well as to treat them successfully should they occur. The most common even though rare, complications resulting from tooth extractions, periodontal therapy, cyst removal, biopsies, filling, root canal therapy, crowns, veneers, bridges, etc, are:

Bleed heavy enough to stop therapy.
Injury to adjacent teeth and fillings.
Post-operative infection requiring additional treatment
Possibility of a small piece of root being left in the jaw when its removal would require extensive surgery.
Fracture or breakage of the jaw.
Post-operative discomfort and swelling which may necessitate several days of home recuperation.
Stretching of the corners of the mouth resulting in cracking and bruising.
Nerve injury, sensory andor/ motor, adjacent or on the side of the surgical site, especially underlying the teeth resulting in numbness of the palate, lips, tongue, chin, face, or other anatomical structures in the head and neck.
Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
Tooth sensitivity, which may require additional treatment.
Tooth Mobility.
Recession of gingival (gums).

Patient or guardian's signature