We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions, we will be glad to help you. We look forward to working with you in maintaining your dental health.

PATIENT INFORMATIONName

Last Name First Name InitialAddress

City

Home #

SSN

State Zip

Cell # Email

Male FemaleSex Age Birthdate

Employed by

Whom may we thank for referring you?

Emergency Contact Home #

Cell # Business # Email

PRIMARY INSURANCEPerson Responsible for Account

Last Name First Name Initial

Relationship to Patient Birthdate SSN

Address (if different from patient) City

State Zip Cell #Home #

Person Responsible Employed by

Business Address

Business # Business Email

Insurance Company Phone # Email

Contract # Group #

Occupation

Subscriber #

Name(s) of other dependent(s) under this plan

ADDITIONAL INSURANCEIs patient covered by additional insurance? Yes No Subscriber Name

Relationship to Patient SSNBirthdate

CityAddress (if different from patient)

State Zip Cell #Home #

Name(s) of other dependent(s) under this plan

Insurance Company Phone # Email

Contract # Group # Subscriber #

Subscriber Employed by

Business EmailBusiness #

Please complete the next section. Dr. Kenneth Yorgey, DMD PC - 2009

804-932-5396 3215 Rock Creek Villa Drive, Suite F

Quinton VA 23141

Single Married Widowed Separated Divorced

Occupation Business #

Business Address Business Email

Instructions on submitting this form via email: 1. With the form open and populated, go to "File", "Save Page As" and save. 2. Send form as an attachment in your email program to kenyorgey@quintondentist.com.

DENTAL HISTORYWhat would you like us to do today?

Former Dentist Address Phone #

Date of Last Dental Care Date of Last X-rays

How often do you brush? Floss?

Other information about your dental health or previous treatment

MEDICAL HISTORYPhysician Phone # Date of Last Visit

Have you had any serious illnesses or operations?

If yes, please describe

Yes No

Are you currently under physician care?

If yes, please describe

Have you ever had a blood transfusion? If yes, give approximate dates

Have you ever taken Fen-Phen/Redux?

Please mark circle, if you have had any of the following (check all that apply): AIDS/HIV Positive

Anemia

AsthmaAtopic (allergy prone)

Blood diseaseCancerChemical DependencyChemotherapy

Cough, persistent

List medications you are taking, if any List drug allergies, if any

AUTHORIZATIONI have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Payment is due in full at time of treatment, unless prior arrangements have been approved.

DateSignature

Cough Up BloodDiabetesEpilepsy

FaintingFood Allergeries

HeadachesHeart murmurHeart problems -

Describe

Hemophilia/Abnormal bleeding

Herpes

Kidney disease/malfunctionLiver disease

Material allergies (latex, wool, metal, chemicals)

Respiratory disease

Yes No

Rheumatic/Scarlet Fever

Shortness of breathSinus problemsSkin rashSpina Bifida

Thyroid disease/malfunction

TonsillitisTuberculosis

Other -

Describe

Yes No

NoYes

Dr. Kenneth Yorgey, DMD PC - 2009

How do you feel about the appearance of your teeth?

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? Yes No

Please mark Yes or No for the following:

Bad Breath

Bleeding Gums

Clicking or popping jaw

Food collection between teeth

Grinding/clenching teeth

Loose teeth/Broken fillings

Periodontal Treatment

Sensitivity to cold

Sensitivity to hot

Sensitivity to sweet

Sensitivity when biting

Sores/growths in mouth

Women: Are you pregnant? Nursing? Taking birth control pills?

Yes No

Yes No

Anaphylaxis

Arthritis/RheumatismArtificial heart valvesArtificial Joints

Back Problems

Circulatory problemsCortisone treatments

Glaucoma

Hepatitis

High blood pressureJaw pain

Mitral valve prolapseNervous problemsPacemaker/Heart surgery

Yes No

Psychiatric care

Rapid weight gain/lossRadiation treatment

Shingles

StrokeSurgical implantSwelling of feet/ankles

Tobacco habit

Ulcers/ColitisVeneral disease

Yes No Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

NoYes

NoYes

Yes No