Have you ever called Mark only to discover that he’s on the telephone or away from his desk? You leave a message and he calls you back, but you’re with a patient. Then you call back and he’s not available. What a HASSLE!

Let’s make a pact to not do that anymore.

Simply fill out the form below and note when you know you’ll be available and Mark will make sure that he holds all other calls, has used the restroom, has eaten his lunch and has all your information ready to talk with you without wasting your time (after all, you are more rigidly booked than he ever will be).

If you would rather talk to someone, don’t hesitate to call the office and Sue or Deanna will make sure to update Mark’s calendar for you.

If you are human, leave this field blank.

Patient's Full Name: *

Date of Birth (mm-dd-yyyy) *

Is your general health good? *

Yes

No

If "No", please explain...

Has there been a change in your health within the last year? *

Yes

No

If "Yes", please explain...

Are you being treated by a physician now? *

Yes

No

Name of your physician

Date of last medical visit...

Have you had, or do you have, any of the following? Check all that apply. *

Damaged heart valve

Pacemaker

Headaches/migraines

Digestive problems

Kidney disease

Hay Fever

Emphysema

Chemotherapy or radiation treatment

HIV or AIDS

Chemical dependency

Seizures

Cosmetic surgery

Artificial heart valve

High blood pressure

Blood disorder

Eating disorder

Diabetes

Tuberculosis

Lung disease

Arthritis

Sexually transmitted disease

Alcohol dependency

Herpes

Stent

Heart attack/disease

Stroke

Hepatitis/liver disorder

Acid reflux disease

Asthma

Persistent Cough

Cancer/tumor

Skin disease

Psychiatric problems

Tobacco habit

Artificial joint

Describe any surgeries that you have had.

Have you been diagnosed with sleep apnea? *

Yes

No

Do you have a CPAP machine?

Yes

No

If you do, are you happy with it?

Yes

No

Are you allergic to, or have had serious reactions to: *

Aspirin

Latex

Codeine

Penicillin

Local anesthetic

Antibiotics

Novocain

Other non-food substances

Do you have any food allergies? *

Yes

No

If "YES", please explain.

Please list supplements, prescription or recreational drugs you are taking.

Are you currently taking, or have taken any of these in the last three months? *

Recreational drugs

Aspirin

Fosomax

Reclast

Skelid

Coumadin

Actonel

Didronel

Antibiotics

Plavix

Boniva

Zometa

Tobacco in any form

None

Do you have, or have you had, any medical problems or diseases not on this form? *

Yes

No

If "Yes", please explain...

Have you ever been pre-medicated for dental treatment? *

Yes

No

If "Yes", please explain...

Have you ever taken Fen-phen? *

Yes

No

If "Yes", please explain...

Is there any issue or condition that you would like to discuss with the dentist in private? *

Yes

No

For Women Only

Are you or could you be pregnant?

Yes

No

Are you or could you be pregnant?

Yes

No

Are you taking birth control pills?

Yes

No

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically- compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Digital Signature of Patient or Minor Patient's Parent/Guardian (Simply type your name) *

Today's Date *

If you want to print the completed page for your records, you must do so BEFORE you send us the form.