Today's Date

MM

DD

YYYY

Birthday

MM

DD

YYYY

Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

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Cell Phone

(###)

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Work Phone

(###)

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Name

First Name

Last Name

Birthday

MM

DD

YYYY

Work Phone

(###)

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Address 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Claims Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company Phone

(###)

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Name of Insured

First Name

Last Name

Claims Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company Phone

(###)

###

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Name of Insured

First Name

Last Name

Birthday of Insured

MM

DD

YYYY

Name

First Name

Last Name

Home Phone

(###)

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Cell Phone

(###)

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Work Phone

(###)

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Name of Physician

First Name

Last Name

Phone

(###)

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DO YOU HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK THOSE THAT APPLY:

* This condition may require antibiotic premedication for certain dental procedures.

Allergies/Hay Fever

Anemia

Angina

Arthritis

Artificial Joints*

Artificial Heart Valves*

Asthma

Breathing Problems

Cancer

Chemical Dependency

Chemotherapy

Diabetes

Epilepsy or Seizures

Excessive Thirst

Fainting or Dizziness

Fever Blisters/Cold Sores

Frequent Cough

Glaucoma

Heart Disorder (Congenital)

Heart Infection*

Heart Murmur

Heart Pace Maker

Heart Surgery*

Hepatitis

High Blood Pressure

HIV*/AIDS

Kidney Problems

Liver Problems

Mental Disorders

Mitral Valve Prolapse Osteoporosis

Radiation Treatment

Respiratory Problems

Rheumatic Fever

Rheumatism

Sickle Cell Disease

Sinus Problems

Stroke

Surgical Shunt*

Thyroid Problems

Tuberculosis

Ulcers

Venereal Disease

Yellow Jaundice

Do you have any health problems that were not listed above or need further clarifications?

Yes

No

Are you now under the care of a physician? *

Yes

No

Have you been admitted to a hospital or needed emergency care during the past two years?

Yes

No

Are you taking any medications or herbals? *

Yes

No

Are you allergic to any medications or substances? *

Yes

No

If yes, check box below:

Aspirin

Penicillin

Codeine

Iodine

Metal

Latex

Other

Have you used tobacco?

Yes

No

Women (Please Check)

Pregnant

Trying to get pregnant

Nursing

Taking oral contraceptives

Antibiotics that have been shown to interact with birth control pills include rifampin (Rifadin®), and to a lesser extent, amoxicillin, Bactrim®, tetracycline, minocycline, metronidazole (Flagyl®) and nitrofurantoin (Macrobid® or Macrodantin®).

I acknowledge that to the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medications change, I will inform the dentist and the staff at the next appointment without fail.

General Consent to Treatment

I agree and consent to a dental examination by Dr. Eunseok Eugene Oh, Anthony Palumbo or Emily Eunyoung Kim. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed.

Release of Information

I authorize Dr. Eunseok Eugene Oh, Anthony Palumbo or Emily Eunyoung Kim to release any information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals.

Assignment of Insurance Benefits

I authorize and request my insurance company to pay my benefits directly to Dr. Eunseok Eugene Oh, Anthony Palumbo or Emily Eunyoung Kim.

Photography Release

I authorize Dr. Eunseok Eugene Oh, Anthony Palumbo or Emily Eunyoung Kim to take photographs of me to help me better understand my current dental condition and possible treatment options. I also authorize him to show these photographs to other patients to better explain their treatment options.

Please Check the Following

I understand and will comply with office Appointment Policy.

I understand and will comply with the office Financial Policy.

I understand and agree to the General Consent to Treatment.

I authorize the Release of Information.

I authorize Photographs to be taken of me and shown to other patients.

I acknowledge that to the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medications change, I will inform the dentist and the staff at the next appointment without fail.