Consent FormStep 1 of 425%Name First Last Gender Female Male Prefer not to say OtherPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dental InsuranceDo you have Dental Insurance? Yes NoMedical HistoryAlthough dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Please answerthe following medical history questions as correctly as possible.Are you currently under the care of a Physician? Yes NoPhysician's Name First Last Physician's Phone NumberHave you ever had or currently have any of the following?AbscessEpilepsy/ SeizuresHigh/ Low blood pressureRheumatic feverAllergies to drugsEye disorderHIV infectionSinus problemsAllergies to a11esthetic.sFaintingKidney diseaseSkin rashAnemiaFay feverLiver diseaseStomach problemsArtificial jointsGlaucomaMental disordersStrokeArthritisRheumatismHeadachesNeurological problemsThyroid problemsAsthmaHead injuriesOrgan TransplantTonsillitisBleeding disorderHeart-diseaseOsteoporosisTuberculoslsCancerHeart murmurPace makerUlcer/ ColitisChemical dependencyHemophiliaPregnancyVenereal diseaseChemotherapyHepatitis BHepatitis CRadiation treatmentDiabetesHernia repairRespiratory diseaseOtherPlease select all that apply.Are you allergic to any of the following?AspirinCodeineLatex (rubber)Local AnestheticsNarcoticsPenicillinSulfa DrugsOtherPlease select all that apply.I prefer a list view View ListHave you ever had or currently have any of the following? Abscess Epilepsy/ Seizures High/ Low blood pressure Rheumatic fever Allergies to drugs Eye disorder HIV infection Sinus problems Allergies to a11esthetic.s Fainting Kidney disease Skin rash Anemia Fay fever Liver disease Stomach problems Artificial joints Glaucoma Mental disorders Stroke Arthritis Rheumatism Headaches Neurological problems Thyroid problems Asthma Head injuries Organ Transplant Tonsillitis Bleeding disorder Heart-disease Osteoporosis Tuberculosls Cancer Heart murmur Pace maker Ulcer/ Colitis Chemical dependency Hemophilia Pregnancy Venereal disease Chemotherapy Hepatitis B Hepatitis C Radiation treatment Diabetes Hernia repair Respiratory disease OtherPlease check all that apply.Are you allergic to any of the following? Aspirin Codeine Latex (rubber) Local Anesthetics Narcotics Penicillin Sulfa Drugs OtherOther Add RemoveAre you currently Pregnant? Yes NoPregnancy MonthPlease enter a number from 1 to 12.Other Add RemoveDo you have any conditions that are not listed above that we should know about? Yes NoAre you taking medications? Yes NoDo you have any complications or allergic reactions if you have or have had any, Yes NoHas your doctor told you to take antibiotic medication before dental treatment? Yes NoDo you take a Bone---building drug? Yes NoAre you nursing? Yes NoAre you taking oral contraceptive? Yes NoX-rays can cause fetal development problems and some antibiotics can affect birth control efficiency. I Understand.Name First Last SignatureDental HistoryHave you ever had or currently have any of the following?Abnormal bleeding after dental care Food impactionBad breathFrequent snackingBleeding gumsGag easilyBrushing FrequencyInter dental stimulationsClenching or grindingJaw painClicking or popping jawLoose or broken fillings/ teethCough up bloodMouth breathingCold I Canker sores or blistersOral habits, i.e. suck thumbComplication from extractionOrthodontic treatmentDental Floss FrequencyPain around earDisclosing tablets or solutionPeriodontal treatmentDry mouthReceding gumsFluoride supplementsSensitive/ sore gumsOtherPlease check all that apply.I prefer a list view View ListHave you ever had or currently have any of the following? Abnormal bleeding after dental care Food impaction Bad breath Frequent snacking Bleeding gums Gag easily Brushing Frequency Inter dental stimulations Clenching or grinding Jaw pain Clicking or popping jaw Loose or broken fillings/ teeth Cough up blood Mouth breathing Cold I Canker sores or blisters Oral habits, i.e. suck thumb Complication from extraction Orthodontic treatment Dental Floss Frequency Pain around ear Disclosing tablets or solution Periodontal treatment Dry mouth Receding gums Fluoride supplements Sensitive/ sore gums OtherPlease check all that apply.Any previous Dental Treatments? Yes NoIf Yes, list all dental treatments Add RemoveChief Oral ComplaintReason for Today's VisitDate of Last Dental Visit MM slash DD slash YYYY To the best of my knowledge, alt of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail, I Agree.Name First Last Date MM slash DD slash YYYY