Personal InfoName Social Securty # Birth Date MM slash DD slash YYYY Employer Name of Spouse Address Street Address City State / Province / Region ZIP / Postal Code Who may we thank for referring you to our office?Newspaper AdNewspaper InsertValpakTV CommercialOnline DealContact InfoCell #Home #Work #Email Emergency Contact: Name Emergency Contact: Number Insurance CoverageInsurance Company Name Policy Number Name of covered employee Social Security of cover employee AUTHORIZATION & releaseI 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 HistoryPlease complete all sectionsName Date MM slash DD slash YYYY Medications: (Including "over the counter" i.e. aspirin, vitamins) Allergies Penicillin Codeine Latex Other Other* Heart Problems High Blood Pressure Heart Murmur Stroke Heart Attack Heart Value Pace Maker Rheumatic Fever Angina What is your Usual Blood Pressure?* Do you need to take antibiotics before dental appointment? Yes No BleedingDo you bleed easy? Yes No Are you on blood thinners? Yes No Do you have Hepatitis? Yes No DiabetesDo you have Diabetes? Yes No If yes, is your diabetes under control?* Yes No Breathing ProblemsDo you have any breathing problems? Allergies Sinus Problems Snoring (Ask your spouse!*) Asthma Bronchitis None 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 FEMALESAre you pregnant or breast feeding? Yes No If so, when is your due date?* CancerDo 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 QuestionsDo 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/BonesCan 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 Lupus Organ transplant HIV AIDS ARC None 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 Back
