Greg Woodfin, D.M.D.
Sal Cabassa D.M.D
4857 N. Ninth Ave. Pensacola, Fl 32503
Tel 850.477.2180 |
800.757.6453
Fax. 850.484.6447
www.gulfcoastbraces.com
New Patient
Thank you for completing this form. This confidential information will become a part of our patient records.
General Information
Date
Patient’s Name
Preferred Nickname
Address
Street
City
State
Zip
Home Phone
Cell Number
Birthdate
Age
Sex:
Male
Female
Social Security#
School Name
if applicable
School Grade Level
Email address
Special Interests: hobbies, sports, etc.
Siblings (if applicable)
Whom may we thank for referring you to our office
Responsible Party (if different from above)
Name
Address
Street
City
State
Zip
Home Phone
Work Number
Cell Number
Social Security#
Date of Birth
Relationship to Patient
email address
Employer
Occupation
Patient living With
Other Family Members treated Here
Spouse’s Name
Address(if different from above)
Street
City
State
Zip
Home Phone
Work Number
Cell Number
Social Security#
Date of Birth
Relationship to Patient
email address
Employer
Occupation
Dental Insurance
Insurance Company
Group #
Insurance Company Address
Phone #
Insured's Name
Relationship to Patient
Birthdate
SS/ID#
Employer
Do you have dual coverage?
Yes
No
If yes:
Insurance Company
Group #
Insurance Company Address
Phone #
Insured's Name
Relationship to Patient
Birthdate
SS/ID#
Employer
Patient Dental History
Patient’s dentist
Date of last cleaning
Check all that apply to patient
Prior orthodontic evaluation
Yes
Date
Prior orthodontic treatment
Yes
By whom:
History at thumb or finger sucking
Yes
Until what age:
Has either parent had orthodontic treatment
Yes
if yes, please explain
Any missing or extra teeth
Yes
if yes, please explain
Inlury to the head, face, or teeth
Yes
Date
Why did you schedule your visit today?
Family Growth Pattern (it under 18 years)
Father:
Height
Mother:
Height
Patient:
Height
Weight
Has patient reached puberty (adolescent patient only)?
Yes
No
(girls started their menstrual cycle/boys secondary sex characteristics - hair development)
Are there any other dental or medical concerns we should be aware of?
Are there any latex metal or acrylic allergies we should be aware of?
Patient Medical History
Patient’s doctor
Date at last medical exam
Patient’s medical health
Excellent
Good
Fair
Poor
Check all that apply to patient
Any health problems or allergies
Yes
if yes, please explain
Is the patient now:
Under a doctor's care
Yes
if yes, please explain
Taking any medication(s)
Yes
List:
Need to be premedicated
Yes
if yes, please explain
Has the patient ever:
Taking any medication(s)
Yes
List:
Had an unfavorable reaction to any medication(s)
Yes
List:
Please check any of the following which the patient has or has had:
Heart murmur
Speech problems/Therapy
Heart problems
Hyperactivity
Convulsions/Epilepsy
Emotional problems
Cancer
Surgical procedures
Diabetes
Wears contact lenses
Endocrine problems
Glaucoma
Rheumatic/Scarlet lever
Kidney disease
AIDS or HIV positive
Hepatitis/liver disease
Hemophilia
High blood pressure
Bleeding problems of any kind
Allergies/asthma
Hearing impairment
Head, facial lnjuries
Osteoporosis/Osteopenia
Bone Cancer
Mental Health issues
Arthritis/Dexterity
Has patient ever taken intravenous bisphosphonates such as Zometa (Zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has patient ever taken oral bisphosphonates such as Fosamas (alendronate), Actone (ridendronate) Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
In Case of Emergency
Contact Name:
Relationship
Complete Address
Phone
Signature
I understand the above information I have given is correct to the best of my knowledge, that It will be held In the strictest of confidence, and it is my responsiblity to inform this office of any changes in this patient medical status. I also authorize the dental staff to perform the necessary dental services that this patient may need. I further understand that where oppropriate, credit bureau reports may be obtained.
Patient signature / Guardian signature of minor patient