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Date: _________________________ Patient information Patient Name: _________________________________________ DOB: ___________________ Patient SSN:_____________________ Patient Address: ________________________________________________________________________ Home phone: ______________________________________________ Employer:_______________________________________ Zip Code:_________________ Cell phone: _____________________________________________ Employer Phone Number: _______________________________________ Person Responsible (If different from patient): ___________________________________________ DOB:_______________ Dentist: ______________________________________ Family Physician: __________________________________ Emergency contact:_______________________ Phone number:______________________ Relation:__________________________ Insurance Dental Insurance: ___________________________ ________ Sub Date of Birth: ______________ Primary Subscriber: _________________________________ Sub SSN #: ____________________________ Ins Phone: ______________________________ Health History Have you or a family member been here before? __________________Name? ___________________________ Chief Complaint for today’s appointment: ________________________________________________ Is the present problem due to an accident: _________________ Last Physical: ________________ Have there been any changes in your medical history or serious illness in the last year: _______________ Pharmacy Name: ______________________________ Pharmacy Location: ________________________ Do you have (circle all that apply): Anemia, Rheumatic fever, Rheumatic heart disease, Mitral valve prolepses, Congenital heart lesions, Cardiovascular disease, Allergy, Asthma, Hay fever, Hives, Skin rash, Fainting spells, Seizures, Diabetes, Hepatitis, Jaundice, Liver disease, Arthritis, Inflammatory rheumatism, Stomach ulcers, Kidney trouble, Tuberculosis, Low blood pressure, High blood pressure, Venereal disease, HIV or Aids, OTHER: __________________________________________________________________________________________________ Do you have a blood or clotting disorder?:____________________________________________________________________ Are you taking any medication if so please list: ____________________________________________________________ Allergy to any medications?: ___________________________________________________________________________________________ Have you ever had any complications associated with previous dental treatment if so explain: __________________________________________________________________________________________________________________ Women: Are you pregnant: ______________ _____________ I understand that I need to follow up with my general dentist after the completion of my root canal for permanent restoration. Please initial as acknowledgement. I hereby grant authority to Bluegrass Endodontic to perform treatment procedure, including the administration of anesthetics and medication, he/she deems necessary for the care of the patient named above. I have read and understand the patient information sheet provided. __________________________________________________ Signature of Patient/Guardian __________________________________________________ Signature of Doctor ________________________ Date