Gentle Dentistry of Tamarac

GENTLE DENTISTRY OF TAMARAC PATIENT MEDICAL/DENTAL UPDATE INFORMATION

*Date	*Patient name
*DOB	*Sexe Female Male	* #ssh
*Adresse	*City	*Zip code
Home Phone	Cell Phone
Work Phone	*E-mail
Current Insurance	Subscriber #	Subscriber DOB
Emergency Contact	Relationship	Home/Cellphone

Do you have any of those diseases or problems:

Dental information


Medical Information

Are you under the care of a physician ?	Yes	No
Physician Name
Phone
Date of your last dental exam ?
Date of your last x rays
Have you had a serious illness , operation or been hospitalized in the past 5 years ?	Yes	No
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?	Yes	No

Woman Are you pregnant?	YesNo	if Yes, indicate due date
Is Antibiotic pre-medication necessary due to any heart condition or artificial joint?
Yes	No
List any changes in your medical/detal history:
List all medications you are currently taking: