Welcome Form -VDC

Date *

Patient Information

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First Name *

Last Name

Street Address *

Building/Apartment

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ZIP / Postal Code

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Sex:MaleFemaleUnspecified

Date of Birth

Medical Health History

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Do you have, or have you had any of the following? (Please check any that apply)NoneBlood Problems (Anemia)Blood TransfusionHeart ProblemsHeart Murmur, Mitral Valve Prolapse, Heart DefectHeart PacemakerStrokeBone or Joint ProblemsArtificial Joint or ValvesHigh or Low Blood Pressure (Circle One)Tuberculosis or Other Lung ProblemsKidney DiseaseHepatitis, Jaundice or Other Liver DiseaseDiabetes TYPE 1 or TYPE 2Epilepsy or Neurological DisordersThyroid ProblemsArthritisHerpes or Cold SoresAIDS or HIV PositiveCancer/TumorAbnormal Bleeding After Any Surgery (Heavy Bleeder)Hayfever or Sinus TroubleAllergiesAsthma

Are you allergic to, or have you reacted adversely to any of the following?LatexPenicillin or Other AntibioticsLocal AnestheticsCodeine or Other NarcoticsSulfa DrugsBarbiturates, Sedatives, or Sleeping PillsAspirinNone

Are you taking any of the following?AspirinAnticoagulants (Blood Thinners e.g. Coumadin)Antibiotics or Sulfa DrugsHigh Blood Pressure MedicineAntidepressants or TranquilizersInsulin Other Diabetes DrugsNitroglycerinCortisone or Other SteroidsOsteoporosis (Bone Density) MedicineNatural SupplementsNone

Women:Are your pregnant or plant to become pregnantTaking hormones or contraceptives

Dental History

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Date of Last Dental Visit:I don't know exact dateLast 6 months6 months - 1 year1-3 yearsGreater than 4 yearsNever

Date of Last Dental X-ray:I don't know exact dateLast 6 months6 months - 1 year1-3 yearsGreater than 4 yearsNever

Oral Health

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Have you ever been treated for Periodontal (gum) disease?YesNo

Have you ever had Novocaine or other local anesthetic?YesNo

Are you currently Wearing Dentures?YesNo

Age of dentures:Less than 6 Months6 months-3 yearsGreater than 4 Years

Please check any conditions that apply to you below:Pain in Jaw(TMJ)Reeth Grinding/ClenchingUse Tobacco Products DifficultyMouth SoresSensitive TeethBroken/Loose TeethChewing/SwallowingSwollen/Bleeding Gums

Women Patients Only

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Are you currently pregnant?YesNo

Estimated Delivery Date: *

Are you Nursing?YesNo

Are you taking any birth control prescriptions?YesNo

NoteAntibiotics (Such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.

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I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge. I hereby give my consent to the dentist to perform an examination and diagnose my condition. I also give my consent for any preventive or basic restorative procedures which may be necessary. I understand that this consent will remain in effective until treatment is terminated either by me or the dentist.

DisclaimerBy signing below, I acknowledge that I have been informed of the cost of the dental services provided and have chosen to not pay the outstanding balance at this time. I understand that non-payment may result in further collection actions, including potential legal proceedings, and I am fully responsible for any associated fees.

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