Patient Info & Medical History Form: Please Complete and Send

PATIENT INFORMATION

Please Fill Out

Mr.			Date of Birth:
Mrs.			- -
Miss

Social Security Number:

- -

Home Address:

Home Phone:

- -

Employer (If minor, parent's employer):

Business Phone:

- -

Business Address:

Extension #:

Name of Spouse (or Parent's if minor):

Spouse/Parent SSN:

- -

Spouse’s (parent’s) Employer:

Spouse / Parent Birth:

- -

Person to Contact in Case of Emergency:

Relationship to Patient:

Phone:

- -

Physician:

Phone:

- -

Referring Dentist:

Dental Insurance:

Yes

Name of Insured:

Policy / ID Number:

Name of Insurance Company:

Group Number:

INFORMED CONSENT

This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable as a corollary to the planned endodontic therapy performed by Endodontic Associates and any assistant the may require. I agree to the use of local anesthesia sedation, and/or analgesia, depending upon the judgement of the endodontist. Complications of root canal therapy and anesthesia may include swelling, discomfort, infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent. I understand root canal therapy is a procedure to retain a tooth which may otherwise require extraction. Although root canal therapy has a very high degree of clinical success, it is still a biological procedure, so it cannot be guaranteed. Occasionally, a tooth which has had root canal therapy may require retreatment, surgery, or even extraction. I also understand that only the root canal therapy is to be performed at this office. The permanent (outside) restoration (filling, onlay, crown, etc.) will be done by my regular dentist. I understand that medications for pain and sedation may cause drowsiness which can be increased by the use of alcohol or other drugs. I will avoid operating any vehicle or hazardous devices while taking such medications. I further understand that certain medications may cause hives and intestinal problems and, if any of these reactions occur, I am to call the doctor immediately. I understand that it is my responsibility to report any changes in my medical history. All reasonable collection and/or legal costs required to collect fees due Endodontic Associates will be borne by the undersigned. ALL SIGNATURES MUST BE BY PARENT OR GUARDIAN IF PATIENT IS 18 YEARS OR YOUNGER.

I've read the above information and agree with all its terms Date - -

MEDICAL HEALTH QUESTIONNAIRE
Name:
Are you currently under the care of a physician?	Yes No
If yes, please describe:
History of Hospitalization:
Any Allergies:
Medications Presently Taking: (including aspirin, etc.)

(Check each item)	Yes	No	Don't Know	(Check each item)	Yes	No	Don't Know	(Check each item)	Yes	No	Don't Know
Epilepsy or Seizure				Hemophilia				Ulcers
Fainting or Dizziness				Bruise or Bleed Easily				Kidney Problems
Nervousness				Heart Problems or Angina				Venereal Disease
Stroke				Hypertension				Diabetes
Glaucoma				Rheumatic Fever				Thyroid Disease
Cold Sores (Herpes)				Heart Murmur				AIDS / HIV-III Positive
Persistent Cough				Mitral Valve Prolapse				Arthritis
Emphysema				Congenital Heart Lesions				Painful Joint(s) (incl. jaw)
Tuberculosis/PPD Posittive				Heart Surgery				Prosthetic Joint(s)
Asthma				Prosthetic Heart Valve(s)				Hives
Hay Fever				Pacemaker				Steroid Medications
Sinus Problems				Blood Transfusion(s)				Drug Addiction
Anemia				Liver Disease				Alcoholism
Sickle Cell Disease				Yellow Jaundice				Unexplained Weight Changes
				Hepatitis - type:				Cancer / Radiation Therapy

ANY FAMILY HISTORY OF (check all that apply):

Heart Disease

Cancer

Diabetes

Seizures

HAVE YOU EVER HAD OR HAVE YOU NOW: (please check all that apply)

Yes

Don't
Know

1. HAVE YOU EVER BEEN TOLD THAT YOU SHOULD NOT DONATE BLOOD?

2. FEMALES:

Are you taking birth control pills (BCP’s)

Are you or might you be pregnant?

3. DO YOU HAVE ANY DISEASE, CONDITION, OR PROBLEM NOT LISTED ABOVE?

If yes, please describe: