Date: _________________
Whom may we thank for referring you? ______________________________________________________________
PERSONAL INFORMATION:
Mrs.
Ms.
Miss
Mr. Email:_______________________________________
Last Name: ________________________________ First Name: __________________________________ M.I ___________
Address: ________________________________________ City: ________________________ State: ______ Zip: _________
Home Phone: (_____) _______________ Work Phone: (______) _________________ Cell Phone: (_____) ________________
Social Security Number: ______________________________
Sex:
Male
Female
Marital Status:
Date of Birth: ______________________
Single
Married
Divorce
Widow
Separated
Driver License Number: _______________________ State of Issuance: ________________________
Employer: _________________________________________ Position: ____________________________________________
Phone Number: _______________ Ext_____ Where would you like us to reach you? Cell Home Work
Name of person to be contacted in case of emergency: _________________________________________________________
Phone Number: _____________________________________ Relationship: ________________________________________
DENTAL INSURANCE INFORMATION:
Dental Insurance Company: _________________________________ ID Number: ___________________________
Group Number: __________________ Plan type:
Relationship to Insured:
Self
PPO
Spouse
Child
HMO
Indemnity
Parent
Insured’s Name: __________________ Social Security Number: __________________ Date of Birth: ____________
HEALTH INSURANCE INFORMATION:
Health Insurance Company: ____________________________________ ID Number: _________________________________
Group Number: __________________ Plan type:
Relationship to Insured:
Self
Spouse
PPO
Child
HMO
Indemnity
Parent
Insured’s Name: ___________________________ Social Security Number: __________________ Date of Birth: ___________
FAMILY MEMBERS:
Name
Age
Relation
Last Dental Visit
1.
2.
3.
15825 Laguna Canyon Rd., #206 Irvine, CA 92618 www.ocdentalspecialists.net 949-789-8989 F: 949-453-0970
PATIENT MEDICAL/DENTAL HISTORY
General Health Questions
Has there been any change in your general health within the past year
Yes
No
If yes, please explain: ____________________________________________________________
Have you been hospitalized within the past five years
Yes
No
If yes, please explain: ____________________________________________________________
Are you required to take antibiotics before any dental treatment
Yes
No
When was your last complete dental check-up and cleaning: ____________________________?
Have you ever been treated for periodontal disease (gum disease) (pyorrhea) (trench mouth)
Name, Address, Phone Number of your general dentist:
__________________________________________________________________________________________________
________________________________________________________________________________________
Name, Address, Phone Number of your medical physician:
__________________________________________________________________________________________
________________________________________________________________________________
Mouth/Teeth:
Do you have or have you had:
Burning tongue/lip
YES or NO
Bleeding, sore gums
YES or NO
Loose teeth
YES or NO
Unpleasant taste
YES or NO
Clenching/grinding
YES or NO
Swollen lumps or infections YES or NO
Do you wear a Night Guard?
YES or NO
Clicking or popping jaws
YES or NO
Orthodontic treatment:
YES or NO
Difficulty opening jaw
YES or NO
Food Impaction
YES or NO
Any change in bite. Please explain
Sensitive teeth
YES or NO
______________________________________________
If YES, check those that apply:
hot
Temporomandibular joint problems (TMJ) YES or NO
Age: ________ How many years? ______________
cold
sweets
YES or NO
pressure
15825 Laguna Canyon Rd., #206 Irvine, CA 92618 www.ocdentalspecialists.net 949-789-8989 F: 949-453-0970
Medications:
Are you taking any of the following (Please provide us a list of medications you are currently taking)
Antibiotics, sulfa drugs
Anticoagulants; (blood thinners, Coumadin, Aspirin, etc)
Medicine for high blood pressure
Steroids
Antihistamines, Aspirin
Medication to treat diabetes
Nitroglycerine
Phen-Fen: _________ How long ago was your last heart exam: __________________________
Please list all the medications you are currently taking. Include the dosage, how often, and if applicable, the
reason you are taking it.
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you required to take antibiotics before any dental treatment due to a heart murmur or mitral valve
prolapse?
YES
NO
Please let us know of any allergies, medical problems, etc that has not been listed on these forms
immediately! Thank you! 
Allergies:__________________________________________________________________________________
________________________________________________________________________________
Are you allergic to Latex
?
YES
NO
Are you allergic to a specific antibiotic or anesthetic before any treatment?
YES
NO
To the best of my knowledge the information above is current and accurate. I have listed all medications I am currently
taking and listed all products that I am allergic to. I understand that it is my responsibility to notify the office of any
changes in intake or allergies.
Patient’s Signature: __________________________________ Date: __________________________
Doctor’s Signature: ___________________________________ Date: __________________________
15825 Laguna Canyon Rd., #206 Irvine, CA 92618 www.ocdentalspecialists.net 949-789-8989 F: 949-453-0970
I. Circle Appropriate Answer (leave blank if you do not understand the question):
1.
2.
3.
Yes
Yes
Yes
No
No
No
4.
5.
6.
Yes
Yes
Yes
No
No
No
Are you in good health?
Has there been a change in your health within the last year?_______________________________________
Have you been hospitalized or had a serious illness in the last three years?
If YES, why? _____________________________________________________________________________
Are you being treated by a physician now? For what? ____________________________________________
Have you had problems with your prior dental treatment?
Are you in pain now? ______________________________________________________________________
II. Have You Experienced:
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Chest Pain (angina)?
Swollen ankles?
Shortness of breath?
Recent weight loss, fever, night sweats?
Persistent cough, coughing up blood?
Bleeding Problems, bruising easily?
Sinus Problems?
Difficulty Swallowing?
Diarrhea, constipation, blood in stools?
Frequent vomiting, nausea?
Difficulty Urinating?
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Dizziness?
Ringing in ears?
Headaches?
Fainting spells?
Blurred vision?
Seizures?
Excessive thirst?
Frequent urination?
Dry mouth?
Jaundice?
28.
Yes
No
Joint pain, stiffness?
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
AIDS?
Tumors, cancer?
Arthritis, rheumatism?
Eye Disease?
Skin disease?
Anemia?
VD (syphilis or gonorrhea?)
Herpes?
Kidney, bladder disease?
Thyroid, adrenal disease?
Diabetes?
III. Do You Have or Have You Had:
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Heart Disease?
Heart attack, heart defects?
Heart murmurs?
Rheumatic fever?
Stroke, hardening of arteries?
High blood pressure?
Asthma, TB, emphysema, other lung disease?
Hepatitis, other liver disease?
Stomach problems?
Allergies to: Drugs, foods, medication, latex?
Family history of diabetes, heart problems, tumors?
IV. Do You Have or Have You Had:
51.
52.
53.
54.
55.
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Psychiatric care?
Radiation treatment?
Chemotherapy?
Prosthetic heart valve?
Artificial joint?
56.
57.
59.
60.
Yes
Yes
Yes
Yes
No
No
No
No
Hospitalization
Blood transfusions?
Surgeries?
Contact lenses?
V. Are you taking?
61.
62.
Yes
Yes
No
No
Recreational Drugs?
Drugs, medications, over-the-counter medicines
(Including Aspirin), natural remedies?
63.
64.
Yes
Yes
No
No
Tobacco in any form?
Alcohol?
Are you or could you be pregnant or nursing?
66.
Yes
No
Taking birth control pills?
VI. Women Only:
65.
Yes
No
VIII. All Patients:
67.
Yes
No
Do you have or have you had any other diseases or medical problems NOT listed on this form?_______________
To the best of my knowledge, I have answered every question completely and accurately, I will inform my dentist of any changes
in my health and/or medication.
15825 Laguna Canyon Rd., #206 Irvine, CA 92618 www.ocdentalspecialists.net 949-789-8989 F: 949-453-0970
Patient Signature: ___________________________ Date: ___________ Doctor’s Signature:________________ Date:______
Financial Terms and Conditions
Assignment and Release of Insurance Benefits
All Patients are required to read and sign this form.
ASSIGNEMENT OF INSURANCE BENEFITS:
I, the undersigned certify that I (or my dependants) have insurance coverage with ___________________________ and assign
directly to OCDS all insurance benefits, if any, otherwise payable to me for services rendered, I understand that I am financially
responsible for all changes whether or not paid by my insurance. I here-by authorize the doctor to release all information necessary
to secure the payment of benefits, I authorize the use of this signature on all insurance submissions.
______________________________
Patient’s Signature
______________________
Date
FINANCIAL RESPONSIBILITY AGREEMENT:
I understand that I remain financially responsible for all treatment performed by OCDS Doctors. In the event that insurance is to pay
for part of my treatment I agree to pay the full co-payment amount at the time of service, unless prior financial arrangements were
made in advance of treatment. In the event insurance is to be billed, I understand that the patient remains financially responsible for
all charges incurred. I further understand, OCDS will assist with the billing of my insurance company as a courtesy. However, OCDS is
under no responsibility to insure that the insurance company will reimburse me for any services rendered on my behalf. I
understand that my account may be turned over to a collection agency if I fail to pay the balance on my account.
I have read the above financial terms and conditions and fully agree to their consent.
If you are unable to keep your appointment, please give us 48 hours notice to avoid any charges to your account.
Any missed or cancelled appointments without 48 hours prior notice will result in the following charges:
Doctor appointment: $50.00 per scheduled hour
Hygiene appointment: $25.00 per scheduled hour
______________________________
Patient’s Signature
_____________________
Date
15825 Laguna Canyon Rd., #206 Irvine, CA 92618 www.ocdentalspecialists.net 949-789-8989 F: 949-453-0970