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Please fill the form and click on the SUBMIT button on the bottom of this form. All fields with * are required.
* Prefix: Mr.    Mrs.   Miss   Ms. 
* Last Name:      * First Name:      Middle Name:
* Marital Status: Single    Married   Divorced   Separated   Vidow 
Nick Name:      * Birth Date:      * Age:      * Sex: Male    Female 
Social security #:      Driver License #:      * D.L. State:      * D.L. Expiration:
* Street Address:      Unit / Apt #:
* City:      * St:      * Zip:
* Home Phone:      Cell Phone:      Email:
Occupation:      Employer:      Employer phone no:
* Chose clinic because/referred to clinic by:
Dr.    Insurance Plan   Web   Family   Friend   Close to home/work   Penny saver   Other (Specify):
Other family member seen here:
Person responsible for bill:
Address (If different):      Phone:      Date of birth:
Is this person a patient here?:   YES     NO
Occupation:      Employer:
Employer Address:      Employer phone no:
Is this patient covered by insurance?:   YES     NO
Please indicate Primary Insurance:
Insurance name:      Ins. phone:
Subscriber Name:      Subscriber S.S. no.:      Subscriber birth date:
Group no.:      Policy no.:      Plan:
Patient's relationship to subscriber:
Name of secondary insurance (If applicable):      Group no.:      Policy no.:
Subscriber's name:
Patient's relationship to subscriber:
Name of friend or relative not living with you:      Realtionship to patient:
Home phone:      Work phone:
* Why have you come to see us? (e.g.: pain, checkup, etc.)
Previous dentist:      Last visit:      Date of last cleaning:
Reason for changing dentist:
Problems with past dental treatments:
Are you nervous about seeing a dentist?:   YES     NO     If you please, tell us why:
How often do you brush?:      Do you floss?   YES     NO     How often?:

Please check all that applies to you below:
I clench and grind my teeth during the day or while sleeping. My gums bleed while brushing or flossing.
I would like to improve my smile. I prefer tooth-colored fillings.
I avoid brushing part of my mouth due to pain. My gums feel tender or swollen.
I have problems eating. I have had orthodontics.
I have had a facial or jaw injury. I want my teeth straighter.
I want my teeth whiter.
What are your dental priorities?: (e.g.:appearance, dental health, financial considerations, etc.)
* I consider my health to be (check one): Excellent    Good   Fair   Poor 
Do you have or had any of the following?: (Check all that applies)
1. Heart disease 2. Heart murmur/Mitral valve prolapse 3. Stroke
4. Congenital heart lesions 5. Rheumatic fever 6. Pacemaker
7. Stent 8. Abnormal blood pressure 9. Anemia
10. Prolonged bleeding disorder 11. Tuberculosis or lung disease 12. Asthma
13. Hay fever 14. Sinus trouble 15. Epilepsy/Seizures
16. Ulcers 17. Epilepsy/Seizures        Hip-Knee    Other:
18. I smoke or use chewing tobacco   

If yes, how much per day?  How many years?
19. I have consumed alcohol within the last 24 hours                20. I usually take an antibiotic before the dental treatment   
21. Have you ever taken Fen-Phen or Redux?   
22. Do you take or have you ever taken Bisphosphonates (Fosomax, Boniva, Actonel, Aredia, Zomotel, etc.) for Osteoporosis or any other condition?   
23. I have had major surgery   

Year  Type of operation

Year  Type of operation
24. Do you have any other medical problem or medical history NOT listed on this form? 
25. Liver disease                       26. Jaundice                       27. Hepatitis   Type 
28. Diabetes 29. Excessive urination and/or thirst 30. Infectious Mononucleosis ("Mono")
31. Herpes 32. Arthritis 33. Sexually transmitted/Venereal diseases
34. Kidney disease 35. Tumor or malignancy 36. Cance/Chemotherapy
37. Radiation/Therapy 38. History of drug addiction 39. HIV
40. AIDS 41. Immune Suppressed Disorder 42. Hearing Loss
43. Fainting Spells 44. Glaucoma 45. History of emotional or nervous disorder
WOMEN:      46. Are you taking birth control medication?            47. Are you or could you be pregnant or nursing? 
Are you allergic to any of the following?: (Check all that applies)
48. Aspirin  49. Ibuprofen  50. Sulfa drugs/Sulfites/Sulfides  51. Penicillin  52. Codein 
53. Latex, Metals, Plastics  54. Local Anesthetics (Novacain, Lidocaine)
55. Other medications        Which ones? 
Please list all medications you are currently taking:
Medicine:  Condition: 
Medicine:  Condition: 
Medicine:  Condition: 
Medicine:  Condition: 
Medicine:  Condition: 
Physician's Name:         Phone:    Fax: 
Physician's Address: 
In event of emergency please contact:
Name:   Relationship:   Telephone: 
Name:   Relationship:   Telephone: 

18607 Ventura Blvd. #209
Tarzana, CA 91357

Call Us Now   818-578-8665
Fax:       818-578-8684
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