Name First Middle Last Birthdate MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SexMaleFemalePhone (residential)Phone (Business)Phone (cell)Email Nickname Marital StatusSingleMarriedSocial Security NumberEmployed By Position Spouse's Name (if applicable) First Last Social Security NumberSpouse's Employer Potition PhoneEmergency Contact Relationship PhoneDo you have or have you ever had any of the following? (check if the answer is YES) Heart Murmur Heart valve dysfunction Prosthetic device (hip or joint repl. pins, plates) Rheumatic fever Need to be premeditated due to medical condition Abnormal blood pressure Blood transfusion Hemophilia/ blood disorder Anemia Prolonged bleeding Positive to HIV Hearing problems ulcer Epilepsy Arthritis Asthma Glaucoma Sinus problem Stroke Thyroid disorder Tuberculosis Novocaine allergy Drug allergy Other allergy Circulatory Problems Emphysema Diabetes Hepatitis Tobacco use Smoking Alcohol/drug dependency Psychiatric care Cancer Radiation Theropy Demensia Currently Pregnant Are you taking any medications? Yes No If yes, please list:Other physical conditions:Is there anything about your smile you would like to change?Would you like whiter teeth? Yes No Do you have dental insurance?* Yes No To the best of my knowledge, all information on this form is correct. I accept responsibility for any bill incurred during treatment. I understand that while my insurance may cover a portion of my bill, my insurance is ultimately responsible to me, and that I am responsible to Blue Ridge Dental Center, P.A. A 1.5% monthly interest charge will be added to unpaid balances over 90 days.I understand that Blue Ridge Dental Center reserves the right to charge for missed or canceled appointments without 24 hour advanced notice.Signature of responsible party:Consent to Text Messaging I allow Blue Ridge Dental to contact me through text messages.
