Patient Information:
First Name: Last Name:
Date of Birth: SSN: - -
Home Phone: - - Work Phone: - -
Address: City: State: Zip:
Male Female Single Married Widowed Divorced
Patient's Employer: Referring Doctor:
If due to accident, please state the date and location of accident:

Responsible Party Information:
Who is reponsible for this account:
Relationship to patient:
Address (if different from patients):
Address: City: State: Zip:
Phone: - -

Primary Insurance:
Do you have primary insurance? Yes No
Medical Ins. Co.: ID # GP #
Dental Ins. Co.: ID # GP #
Name of Insured: DOB of Insured: Relationship to Patient:
Name of Employer:     SS #
Address (if different from patients):
Street: City: State: Zip:
Phone: - -

Secondary Insurance:
Do you have secondary insurance? Yes No
Medical Ins. Co.: ID # GP #
Dental Ins. Co.: ID # GP #
Name of Insured: DOB of Insured: Relationship to Patient:
Name of Employer:     SS #
Address (if different from patients):
Street: City: State: Zip:
Phone: - -

Emergency Contact: (Outside of Home)
Name: Phone: - - Relationship:
Address: City: State: Zip:

Health Questionnaire:
Height: Weight:
Family Physician:
Are you in general good health? Yes No
Are you now under the care of a Physician(s)? Yes No
If so, for what reason(s)?
Check if you have suffered from any of the following:
Rheumatic fever
Heart trouble
Heart murmur
Chest Pain
Shortness of breath
High blood pressure
Low blood pressure
Tuberculosis
Asthma
Temporomandibular Joint Dysfunction
Sinusitis
Allergies
Hepatitis
HIV
Kidney disease
Diabetes
Epilepsy/Seizure
Arthritis
Joint Replacement
Thyroid disease
Are you pregnant?
GERD
Osteoporosis
Cancer
COPD
Is there anything else about your health you want the doctor to know about?
Do you have any drug allergies? Yes No
If yes, please what drugs or medications you have had a reaction to:
Have you ever had an undersirable reaction to an anesthetic? Yes No
Have you ever experienced prolonged bleeding? Yes No
List any operations you have had:
Are you currently taking any medications? Yes No
If yes, please list any medications you are currently taking:
INSURANCE ASSIGNMENT: I hereby assign Dr's Harris, Cole, Blanchaert and Lichty any medical/dental benefits arising out of any policy of insurance insuring the patient or any other person liable for the patient's care to be applied to the charges for services rendered. I also understand that I am responsible for any charges not paid by the insurance company.

The undersigned certifies that he or she has read and understands the foregoing, and is the patient, or is duly authorized by the patient as the patient's general agent to execute the above and its terms. I also certify that the information given by me is true to the best of my knowledge.

The Undersigned certifies he or she has received a copy of the HIPAA Privacy Act.
PATIENT SIGNATURE (if 18 or older)______________________________________ DATE________________________

AGENT/GUARDIAN/REPRESENTATIVE SIGNATURE (if under 18 parent or legal guardian)_____________________________________________________ DATE____________________________

RELATIONSHIP TO PATIENT______________________________________WITNESS______________________________________DATE________________________