The Dental Center 731 Bloomfield Avenue Marc I. Moscowitz,...
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When was your last check-up?_________________________When was your last cleaning? __________________________ When was your last full set of xrays? _______________________________________________________________________ Have you ever had any abnormal bleeding associated with previous extractions, surgeries, or trauma? Are you aware of grinding or clenching your teeth? Have you had any dental anesthesia before? If yes, any adverse reactions? ________________________________________________________________________ Have you had instruction on the correct method of brushing your teeth and care of your gums? Do you have any dental complaints at this time? __________________________________________________________ __________________________________________________________________________________________________ In Case of emergency contact____________________________________________________________________________ Address: _____________________________________________________________________________________________ Home Phone:(_______)_________-___________ Cell Phone:(_______)_________-___________ Work Phone:(_______)_________-___________ yes no yes no yes no Today’s Date: ___________________________ Patient’s Name: _______________________________________________ Social Security # ____________-________-_____________________ Date of Birth:________________________________ Home Address: ________________________________________________________ Apt# _________________________ City _______________________________________ State _____________ Zip Code ______________________________ Home Phone: (_______)_________-________________ Cell Phone: (_______)_________-_________________ Email: ______________________________________________________________________________________________ Employer: ___________________________________________________________________________________________ Business Phone: (_______)_________-________________ How did you hear about us? Referred by _____________________________________________________ Telephone Directory Drive/ Walk By Other ___________________________________________________ Purpose of today’s appointment? ________________________________________________________________________ ___________________________________________________________________________________________________ yes no TELL US ABOUT YOURSELF (PATIENT INFORMATION) EMERGENCY INFORMATION DENTAL HISTORY The Dental Center Marc I. Moscowitz, D.M.D. Carmine Corigliano, D.M.D. 731 Bloomfield Avenue Bloomfield, NJ 07003 (973) 743-5116 1 of 5 Welcome to our office. Please fill out all forms
Transcript of The Dental Center 731 Bloomfield Avenue Marc I. Moscowitz,...
When was your last check-up?_________________________When was your last cleaning? __________________________
When was your last full set of xrays? _______________________________________________________________________
Have you ever had any abnormal bleeding associated with previous extractions, surgeries, or trauma?
Are you aware of grinding or clenching your teeth?
Have you had any dental anesthesia before?
If yes, any adverse reactions? ________________________________________________________________________
Have you had instruction on the correct method of brushing your teeth and care of your gums?
Do you have any dental complaints at this time? __________________________________________________________
__________________________________________________________________________________________________
In Case of emergency contact____________________________________________________________________________
Address: _____________________________________________________________________________________________
Home Phone:(_______)_________-___________ Cell Phone:(_______)_________-___________
Work Phone:(_______)_________-___________
yes no
yes no
yes no
Today’s Date: ___________________________ Patient’s Name: _______________________________________________ Social Security # ____________-________-_____________________ Date of Birth:________________________________Home Address: ________________________________________________________ Apt# _________________________City _______________________________________ State _____________ Zip Code ______________________________Home Phone: (_______)_________-________________ Cell Phone: (_______)_________-_________________Email: ______________________________________________________________________________________________Employer: ___________________________________________________________________________________________Business Phone: (_______)_________-________________ How did you hear about us? Referred by _____________________________________________________ Telephone Directory Drive/ Walk By Other ___________________________________________________Purpose of today’s appointment? ___________________________________________________________________________________________________________________________________________________________________________
yes no
TELL US ABOUT YOURSELF (PATIENT INFORMATION)
EMERGENCY INFORMATION
DENTAL HISTORY
The Dental CenterMarc I. Moscowitz, D.M.D.Carmine Corigliano, D.M.D.
731 Bloomfield AvenueBloomfield, NJ 07003(973) 743-5116
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Welcome to our o�ce. Please �ll out all forms
The Dental CenterMarc I. Moscowitz, D.M.D.Carmine Corigliano, D.M.D.
731 Bloomfield AvenueBloomfield, NJ 07003(973) 743-5116
I hereby state that all of the above is correct and I am fully responsible for all fees incurred which are not covered by anyinsurance payment.
Signature of Patient (or parent/ legal guardian) _____________________________________________________________
Date: __________________________________
Are you under the care of a physician?
If yes, what condition? _________________________________________________________________________________
Name of Physician:____________________________________________________________________________________
Address:_____________________________________________________________________________________________
O�ce Phone # (_________)___________-____________________
Are you currently taking any medication?
If yes, please list medications: ____________________________________________________________________________
____________________________________________________________________________________________________
Do you have or have you had any of the following problems or diseases? (check if yes)
Heart Murmur Heart Problems High Blood Pressure Hepatitis, Jaundice, or Liver Disease AIDS
Any Blood Disease Rheumatic Heart Fever Asthma or Hay Fever Veneral Disease Diabetes
Kidney Ailment Epilepsy Tumors or Growths Other
If yes to any of the above, explain ________________________________________________________________________
Do you have any disease, conditions, or other problems not listed that you think we should know about?
If yes, describe _______________________________________________________________________________________
Are you allergic to any drugs/medications (such as penicillin, codeine, aspirin) or have a latex allergy?
If yes, what are you allergic to? ________________________________
Are you pregnant?
Comments:__________________________________________________________________________________________
____________________________________________________________________________________________________
yes no
yes no
yes no
yes no
yes no
MEDICAL HISTORY
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THERE MAY BE A CHARGE OF $75 PER HOUR FOR ANY MISSED APPOINTMENTS IF WE ARE NOT NOTIFIED 48 HOURS PRIOR TO YOUR APPOINTMENT TIME
