First name *

Middle name

Last name *

Nick name *

DOB *

SS#

Phone # *

Sex *MaleFemale

Address *

City *

State *

Zip *

State ID #/Driver Licence #

Email *

Employer Name *

Work Phone #

Emergency contact name *

Emergency contact phone #

Relationship

Emergency contact phone # *

Physician Phone # *

How did you hear about us?

DO YOU HAVE A HISTORY OF:

HPVYesNo

Radiation treatmentYesNo

MEDICAL QUESTIONS

Date of last medical exam *

List any medication you are taking including nonprescription drugs

Do you smoke or chew tobacco? *YesNo

Are you allergic to any medication? *YesNo

Are you in good health? *YesNo

Have you had a transplant operation that has depredded your immune system? *YesNo

Have you had an allergic reaction to bananas? *YesNo

Do you have any disesse/problmes you think we should know about?YesNo

FOR WOMEN ONLY

DENTAL HISTORY INFORMATION

Date of last dental visit

Name of the previous Dr.?

Reason for today's visit?

How often do you floss your teeth? *

Have you ever had a popping/clicking in your ear when you chew? *YesNo

Do you have blister, or swelling on your gums, lips or cheeks? *YesNo

Do you have problems with bad breath? *YesNo

On a scale of 1-10 (1 being the lowest and 10 being the highest)

I certify that I have read and understood all the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold responsible the dentist or any other member of Hollywood Perfect Smile for any errors I have made in completing this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of anesthetics, sedans, or X-rays as may be deemed necessary by the Doctor.

Patient *

Parent /Guardian (if minor)

Date *

(954) 987-3309

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