Name:_______________________

Name:_______________________________________ Date of Birth: _______________________________ Medical History

Physician’s Name: ___________________ Clinic: __________________ Date of Last Medical Visit: ___________________________
I have had serious illnesses or hospitalizations □ No □ Yes, description: ________________________________________________ I have had a blood transfusion □ No □ Yes, approximate date: ________________________________________________ □ No □ Yes Nursing? □ No □ Yes Oral or Implant Contraceptive? □ No □ Yes
Mark (X) if you have or have had any of the following: Other health concerns not listed below: _______________________________________
□ Anemia
□ Heart Valve Replacement □ Memory Loss (Alzheimer’s, Dementia, etc.)
□ Blood Thinner (Currently taking) □ Epilepsy □ Joint Replacement
□ Cancer _____________ □ Glaucoma
□ Rheumatic Fever
MEDICATIONS
ALLERGIES
ALL medications I am currently taking (including OTC vitamins & supplements): □ See Attached List
_____________________________________________________________

_____________________________________________________________

Other: ________________________________________________________
PREVIOUS SURGERIES

□ Wisdom Teeth □ Dental Implant(s): Year _________ □ Neck/Back □ Joint Replacement □ Cardiac □ Other: __________________
I am required to take preventative antibiotics prior to dental procedures? □ Yes* □ No


*If yes to above, list Physician/Surgeon’s Name & Clinic: ____________________________________________________________

Patient Signature: _____________________________ Today’s Date: ___________________________

DDS Signature: _______________________________ Today’s Date: ___________________________

For office use only: Today’s Blood Pressure Reading: ___________/___________
Medical History Update - to be completed at future visits
Date: ___________________________ BP_____________/______________ Date: ___________________________ BP_____________/______________ Health Changes? □ Yes □ No Describe__________________________________ Health Changes? □ Yes □ No Describe__________________________________ Medication Changes? □ Yes □ No Describe______________________________ Medication Changes? □ Yes □ No Describe______________________________ Patient Signature____________________________________________________ Patient Signature____________________________________________________ DDS Signature______________________________________________________ DDS Signature______________________________________________________ Date: ___________________________ BP_____________/______________ Date: ___________________________ BP_____________/______________ Health Changes? □ Yes □ No Describe__________________________________ Health Changes? □ Yes □ No Describe__________________________________ Medication Changes? □ Yes □ No Describe______________________________ Medication Changes? □ Yes □ No Describe______________________________ Patient Signature____________________________________________________ Patient Signature____________________________________________________ DDS Signature______________________________________________________ DDS Signature______________________________________________________ Date: ___________________________ BP_____________/______________ Date: ___________________________ BP_____________/______________ Health Changes? □ Yes □ No Describe__________________________________ Health Changes? □ Yes □ No Describe__________________________________ Medication Changes? □ Yes □ No Describe______________________________ Medication Changes? □ Yes □ No Describe______________________________ Patient Signature____________________________________________________ Patient Signature____________________________________________________ DDS Signature______________________________________________________ DDS Signature______________________________________________________ Welcome to Buffalo Dental Center!
We are committed to helping you restore & maintain your oral and overall health Patient Information – Please complete ALL lines
Full Name:________________________________ Date of Birth:____________________________ Address:_________________________________ Social Security #:_______-_____-___________ City/State/Zip:___________, _____, __________ Home Phone:_______-_______-______________ Employer/School:_________________________ Cell Phone:______-_______-_________________ Work/School Phone #:_____-_____-__________ Occupation:______________________________ Person Responsible for Account:_______________ E-mail Address: [email protected]________.com
Emergency Contact Name________________, Phone # ____-____-______, Relationship _____________
Preferred method of contact for appointment confirmations: □ Text or Phone call: □ Home □ Cell □ Work

Whom may we thank for referring you?_____________________________________________________
Insurance Information
Primary Insurance
Secondary Insurance
Insured Party:________________D.O.B.________ Insured Party:________________D.O.B.________ Social Security #:________-______-___________ Social Security #:________-______-___________ Employer & Ph. #:__________________________ Employer & Ph. #:__________________________ Insurance Co.:_____________________________ Insurance Co.:_____________________________ Group #:_____________ Subscriber #:_________ Group #:_____________ Subscriber #:_________ Relation to Patient:__________________________ Relation to Patient:__________________________ (Insurance card copied: □ Yes □ No) (Insurance card copied: □ Yes □ No) Dental History
Reason for today’s visit:______________________ Date of last dental care:____________________ Former Dentist name & phone #:__________________________________________________________
Mark (X) if you are currently experiencing or have had any of the following oral/dental concerns:
□ Sensitivity (circle all applicable) I would like to change my smile: □ Straighten
□ Whiten
□ Restore existing teeth
□ Replace missing teeth
□ Other: ___________________
I consume _____ oz. coffee/cappuccino/tea per day Authorization

I understand that I am financially responsible for all charges whether or not paid by insurance.

I certify that I and/or my dependent(s) have insurance coverage with the above listed insurance company(ies) and assign directly to
Buffalo Dental Center all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my
signature on all insurance submissions.
The above named Dentist/Dental office may use my health care information and may disclose such information to other health care providers and professionals for discussion of my treatment, and to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or two years from the date signed below, whichever is longer. _______________________________________________________________________ Signature of Patient, Parent, Guardian or Personal Representative _______________________________________________________________________ Printed name of Patient, Parent, Guardian or Personal Representative Please complete both sides of this form.

Source: http://www.smilebright.org/HealthHistory2013.pdf

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