PLEASE PRINT Date ________________________ SINGLE MARRIED Name______________________________________________________Sex: M F WIDOWED DIVORCED Address_______________________________________________________________ SEPARATED City ______________________________________________________State ___________________ Zip Code ______________ Home Phone ___________________________ Mobile Phone ___________________________ Birthdate _________________ Email ____________________________ Bus. Phone __________________________Soc. Sec. #________________________ Employed By _______________________________________________________ Medical Doctor's Name Occupation _________________________________________________________ ___________________________________ Referred By _________________________________________________________ Dentist's Name Name of Parent / Spouse _____________________________________________ ___________________________________ Person Responsible for Payment If other than Above ______________________________________ Relationship to Patient ( ) Spouse ( ) Parent or Guardian Does This Person Reside in the Same Household? Yes No Address _________________________________________________________________________________________________ City _____________________________________________________State ____________ Zip Code ______________________ SS # __________________________ Home Phone ______ ___________________ Work Phone______ ________________ Employer’s Name __________________________________________________ Occupation ___________________________ Emergency Contact _________________________________________ Phone Number _______________________________ ENDODONTICS LIMITED, P.C. REGISTRATION FORM HEALTH QUESTIONS Is your general health good? ...................................................................................................................... Yes No Are you under a physician’s care now? ..................................................................................................... Yes No Heart Murmur Heart Trouble Mitral Valve Prolapse High Blood Pressure Pacemaker for Heart Phen Fen Diet Artificial Joints Overactive Thyroid Underactive Thyroid Herpes AIDS/HIV Ulcer Diabetes Nervous Disorder Asthma Bleeding Disorders Seizures Osteoporosis Tuberculosis Cancer Rheumatic Fever Hepatitis Currently Pregnant Arthritis Autoimmune Disease Latex Allergy Yes No Yes No Yes No Yes No Have you ever had an allergy or unusual reaction to any drug, general or local anesthetic? (If yes, list) Yes No Is there any other information about your health that should be known? ................................................ Yes No List all medications that you presently take and why: Drug ___________________ Condition ___________________ Drug ___________________ Condition___________________ Drug ___________________ Condition ___________________ Drug ___________________ Condition___________________ Drug ___________________ Condition ___________________ Drug ___________________ Condition___________________ I have been given a copy of “Important Facts About Root Canal Therapy” and have been advised to read it and ask any questions regarding the contents that I do not understand. Signed ______________________________________________________ Dr.________________ If you have Dental Insurance Turn to Back of this Page to Continue