Bay area endo info

BAY AREA ENDODONTICS, LLP
1550 S. HIGHLAND AVENUE, SUITE A • CLEARWATER, FL 33756 • TELEPHONE (727) 443-3231 PLEASE PRINT THE FOLLOWING INFORMATION
Patient ________________________________________________________________________________Dr.
Home Address __________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Other Address __________________________________________________________________________________________________ Employed by _______________________________________________ Occupation ______________________ Dept. ___________ Name of General Dentist _____________________________ Referred by (if different than general dentist): _____________________ Name of Spouse, Parent / Guardian _________________________________________ __________ S.S. No. _____________________ Employed by _______________________________________ Occupation ___________________ Bus. Phone # ________________ Name of Medical Physician _________________________________________________________ Phone ( _____ ) ______________ Cash ____ Check ____ Credit Card ____ Dental Insurance ____ Dental Insurance Information: Subscriber’s Name ___________________________ Birthdate __________ S.S. No. ______________ Insurance Company _____________________________ Policy No. __________ Group No. ___________ Phone ( _____ ) _____________ Insurance Address _______________________________________________________________________________________________ Secondary Insurance: Subscriber’s Name _________________________________ Birthdate __________ S.S. No. ______________ Insurance Company _________________________ Policy No. _____________ Group No. ____________ Phone ( ____ ) __________ Insurance Address ___________________________________________________________________________________________ In case of Emergency Notify ___________________________________ Relationship _____________ Phone _______________ PLEASE ANSWER ALL QUESTIONS
1. Are you now or have you been under the care of a physician in the past 2 years? .
2. Have you ever been hospitalized or had any operations? .
4. Do you need to premedicate with antibiotics before dental treatment for medical reasons? .
5. Have you experienced any unfavorable reaction to previous dental treatment? .
6. Please list any medications you are currently taking: __________________________________________________ 7. Birth Control Pill users must use additional methods while taking antibiotics and for 72 hours afterward.
8. Check any you have had or currently have: ___ PENICILLIN OR OTHER ANTIBIOTICS (if yes, describe) ________________________________________________________________ XYLOCAINE OR OTHER DENTAL ANESTHETICS (if yes, describe) _______________________________________________________ CODEINE OR OTHER PAIN MEDICATION (if yes, describe) ___________________________________________________________ Date ______________ Signature __________________________________________________________________________________

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