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Adult Patient Personal Information
(all information provided is secure and confidential)

Consultation Date:
Zip Code:
Social Security #:
Sex: Male Female
Date Of Birth: D M Y
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Driver's License #:
Marital Status (check one)
Single Common law Married Separated Divorced Widowed

Spouse Name: (if applicable)
Who is your family Dentist?
Have you seen a specialist before?
  Date of last dental   check-up:
  If yes, when?

Have you ever required antibiotics or other medications prior to dental treatment? Yes No

Indicate any history of (check all that apply): Jaw joint problems Grinding and/or clenching of teeth
Thumb/finger sucking Injury to face or teeth Tongue position/or swallowing problems
Tonsils/Adenoids removed Speech/articulation problems Mouth breathing more than nose breathing
Family Physician: Date of last medical check-up:
Are you currently under medical care? Yes No If yes, explain:
Do you have any drug allergies?         Yes No If yes, explain:

Indicate any history of (check all that apply):
Epilepsy or seizures Hereditary problems Asthma Headaches
Hepatitis Heart murmur Heart problems H.I.V. Positive
Diabetes Anemia Prolonged bleeding  
Nickel/metal allergy Latex allergy Rheumatic fever Other:

Who may we thank for referring you?

Reason for today's visit:
I authorize DSI to do a clinical dental examination and photographic documentation.

I consent to the discretionary and anonymous use of clinical photos and x-rays for DSI's educational/teaching purposes.
I consent to having reviewed DSI's privacy policy.
Signature _______________________________________________ Date _______________________________________________
Insurance Plan 1 (please print) Insurance Plan 2 (please print)
Employee's Name: Employee's Name:
Company Name: Company Name:
Insurance Company: Insurance Company:
Group/Policy Number: Group/Policy Number:
Certificate/I.D.: Certificate/I.D.:
Date of Birth (MM/DD/YY): Date of Birth (MM/DD/YY):
Relationship to Patient: Relationship to Patient: