9 Holly Hill Drive
Petersburg, Virginia 23805-2559

(804) 733-9490

FAX (804) 733-3564

10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460

Patient Information:

Patient's Full Name
Age
Date of Birth
Sex
Address
County Of
City, State, and Zip Code
SSN
Patient's Employer
Home Phone
Address
Cell Phone
Spouse's Name
Office Phone
Spouse's Employer
Email Address
Spouse's Work Address
Spouse's Work Phone No.
Whom may we contact in case of an emergency?
Phone No
Who is financially responsible for this bill?
Address
Phone No.
Whom may we thank for referring you to us?

HAVE YOU HAD ANY OF THE FOLLOWING

Heart Murmur
Rheumatic Fever
Diabetes
Heart Condition
Abnormal Blood Pressure
Bleeing Disorder
Hepatitis
Stomach Ulcers
Bleeding Gums
Jaundice or Liver Disorder
Anemia
Asthma or Hay Fever
Epilepsy or Seizures
Lung Disorders (T.B. or Emphysema)
Thyroid Disorder
Arthritis
Glaucoma
Psychiatric Treatment
HIV/Aids
Do you use tobacco?


Are you presently under the care of a physician?
If yes, Explain?
Have you ever had any serious illness or operation?
Explain:
Are you allergic to any foods or medications?
Explain:
Has anyone in your family had diabetes?
lf female, are you pregnant at this time?
lf so, which month?
Are you taking any medication now?
Please list and for what purpose?

Have you ever taken or are you taking:

Cortisone
Tranquilizers
Digitalis
Anticoagulants (blood thinners)
Nitroglycerine
Oral Contraceptives or Hormones
When was the last time you were treated by your dentist?
What was done at the time?

Have you ever had any complications associated with previous dental treatment?

Explain?

Do you have any condition in your mouth that is causing you discomfort or concern?


I fully understand that I am financially responsible for all fees not covered by my insurance company.


Patient Signature:

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Date:

Parent's signature if patient is a minor:

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Name
Date: