Antelope Family Dentistry
Vimal Dulabh, D.D.S., Inc.
PATIENT INFORMATION
Date:_____________
Home Phone:____________________
Cell:____________________
Work:_________________ X__________
Name:_________________________________________________ ______________________ __
SSN:_______________________________
Address:______________________________________________
ST:___________ ZIP:________________
Last Name
Street
Sex  M  F
First Name
MI
Apt #
Age:______ Birthdate:________________
Employer:_____________________________________________
EMERGENCY CONTACT INFORMATION
City:___________________ _
Drivers Lic:____________________
 Single  Married  Divorced
 Separated  Widowed
Address:______________________________________________________
Name_____________________________
Phone #____________________________
Whom may we thank for referring you to our office? _______________________________________________________
E-Mail Address:__________________________________ ___________________________________________________
PRIMARY INSURANCE
Person Responsible For Account:
*Primary Insured / Or Responsible Party if NO Insurance*
 Patient
 Guardian  Spouse
Name: ____________________________________________________
Last Name
First Name
MI
 Father
 Mother
Relationship to Patient:  Self
 Spouse
 Child  Other
Address (If different from patient’s)_________________________________________________
Phone #____________________________
City _______________________________________________________ ST __________________
Zip________________________________
Insured SSN:__________________________
Work #:____________________________
Date of Birth:_____________________________
Insured Employer:_________________________________ Address:_________________________
City, St. Zip____________________
Insurance Company:_______________________
City, St. Zip____________________
Address:________________________
Insurance Phone #:________________________________ Group #_______________________________
ADDITIONAL INSURANCE
*Is patient covered by additional insurance?*
Name: ____________________________________________________
Last Name
First Name
MI
Relationship to Patient:  Self
 Spouse
 Child  Other
Address (If different from patient’s)_________________________________________________
Phone #____________________________
City _______________________________________________________ ST __________________
Zip________________________________
Insured SSN:__________________________
Work #:____________________________
Date of Birth:_____________________________
Insured Employer:_________________________________ Address:_________________________
City, St. Zip____________________
Insurance Company:_______________________
City, St. Zip____________________
Address:________________________
Insurance Phone #:________________________________ Group #_______________________________
DENTAL HISTORY
Reason for Today’s Visit: _______________________________________
Date of last dental care: _________________________________
Former Dentist:_______________________________________________
Phone #:_____________________________________________
Address:_____________________________________________________________________________________________________________
Check  if you have had problems with any of the following:
 Bad Breath
 Loose Teeth or broken fillings
 Food collection between teeth
 Grinding Teeth
 Clicking or popping jaw
 Sores or growths in your mouth
How often do you floss?_________________________________________
 Sensitivity to hot
 Sensitivity to cold
 Sensitivity to sweets
 Bleeding gums
 Periodontal treatment
 Sensitivity to pressure
How often do you brush?_______________________________
MEDICAL HISTORY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health
problems that you may have, or medication you may be taking, could have an important interrelationship with the dentistry you will
receive. Thank you for answering the following questions.
Physician’s Name:___________________________________________
Date of last visit?:________________________________________
Are you under physician’s care now?
 YES  NO
 N/A__________________________________________
Have you ever been hospitalized or had a major operation?
 YES  NO
 N/A__________________________________________
Have you ever had a serious head or neck injury?
 YES  NO
 N/A__________________________________________
Are you taking any medications, pills, or drugs?
 YES  NO
 N/A__________________________________________
Do you take, or have you taken, Phen-Fen or Redux?
 YES  NO
 N/A__________________________________________
Are you on a special diet?
 YES  NO
 N/A__________________________________________
Do you use tobacco?
 YES  NO
Do you use controlled substances?
WOMEN: Are you
 Pregnant/Trying to get pregnant?
 Nursing?
 YES
 NO
 Taking Birth Control?
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?
 Aspirin
 Penicillin
 Codeine
 Acrylic
 Metal
 Latex
 Local Anesthetics
 Other_____________________
DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING?
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AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve**
Artificial Joint**
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
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Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Have you ever had any serious illness not listed above?
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Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur**
Heart Pace Maker**
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
 YES
 NO
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Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse**
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever**
Rheumatism
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Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
 N/A __________________________________________
COMMENTS:___________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
AUTHORIZATION
I certify that I, and/or my dependent(s), have insurance coverage with ______________________________________ and assign directly to
Name of Insurance Company(ies)
Vimal Dulabh, D.D.S., Inc., all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am
financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance
submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance
Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the
benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date
signed below.
_________________________________________________________
____________________________________
______________________________________________________________________
Please print name of Patient, Parent, Guardian or Personal Representative
____________________________________________
Relationship to Patient
Signature of Patient, Parent, Guardian or Personal Representative
Date
PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED.