JC Goodwin DMD, DACSDD, DABDSM

3192 N Windsong Dr. Prescott Valley, AZ 86314

928-778-4555

Patient Information

Date:
Patient's Name:
Date of Birth
Home Address:
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Mailing Address:
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Phone numbers: Home:
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Email address:
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Marital Status:
Emergency Contact: Name
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Relationship

Medical Insurance Information (Please be prepared to present your card(s) and ID)

Primary Co:
ID #
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Name of Primary Person Insured
DOB
Relationship
Secondary Co:
ID #
Group #

Medical History

Primary Care Dr:
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Specialist Dr:
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Dentist:
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Indicate any of the following conditions you may have experienced (Please Select Y or N for EACH item)

Acid Reflux (GERD)
Allergies (environmental)
Angina
Pacemaker
Asthma
Blood Pressure (high)
Blood Pressure (low)
Cancer
Chemical Dependency
Chemotherapy
Chronic Pain
COPD
Depression
Diabetes
Epilepsy / Seizures
Latex Allergy
Lung Disease
Heart Disease
Migraine Headache
Morning Headache
Psychiatric Treatment
Radiation Therapy
Diabetes
Thyroid Disorder
Tuberculosis
Other Significant Health Concern:

List all current Prescription Medications and the reason you are taking them

Medication
for
Medication
for
Medication
for
Medication
for
Medication
for
Medication
for
Are you allergic to any medication?
Which Ones?
Do you currently smoke?
Do you use oral tobacco?
Do you use alcohol?
Do you use sedatives?
Have you had orthodontic treatment?
When?

I believe the information provided above to be complete and accurate. I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician, and I authorize the release of any medical information to insurance companies for legal documentation necessary to process claims.

Signature

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