George E. Walker, DDS

To help us meet all your health care needs, please fill out this form completely.
If you have any questions, please call or email us and we will be happy to help.

Patient Information (Confidential) Email:
Name
Date (mm/dd/yy)
Soc. Sec #:
Birthdate (mm/dd/yy):
Home Phone:
Address: City:
State / Zip

Select : Minor Single Married Divorced Widowed Separated
Student? No Full Time Part Time

If student, Name of School/College:
 City:

State:
Patient's or Parent's Employer:
Work Phone:
Business Address:
City:
State / Zip
Spouse or Parent's Name:
Employer:
Work Phone:
Whom may we thank for referring you?
Person to contact in Case of Emergency:
Emergency Phone:

Responsible Party
Name of Person Responsible for this Account:
 Relationship to Patient:
Address:
 Home Phone:
Driver's License #
 Birthdate: (mm/dd/yy)
 SSN#:
Bank:
Employer:
 Work Phone:
 Current Patient Here?
Yes No
For your convenience we offer the following methods of payment. Please check the option you prefer.
Payment in full at each appointment.
Cash Personal Check Visa MC I wish to discuss the office's payment policy.

Insurance Information
Name of Insured
 Relationship to Patient
BirthDate (mm/dd/yy)
Soc Sec #
 Date Employed
Name of Employer
 Union or Local#
 Work Phone
Employer Address
 City
 State/Zip
Insurance Company
 Group#
 Policy/ID No
Insurance Co Address
 City
 State/Zip
How much is your deductible?
 Amount used?
 Max Annual Benefit?
Do you have any additional insurance? Yes - if "yes" complete the following:
Name of Insured
 Relationshipto Patient
BirthDate (mm/dd/yy)
Soc Sec #
 Date Employed
Name of Employer
 Union or Local#
 Work Phone
Employer Address
 City
 State/Zip
Insurance Company
 Group#
 Policy/ID No
Insurance Co Address
 City
 State/Zip
How much is your deductible?
 Amount used?
 Max Annual Benefit?


Patient Medical History
Physician
 Office Phone
 Date of Last Exam
   YES   NO         

 

 

  YES   NO 
1. Are you under medical treatment now? 9.

Are you allergic or have you had any reactions to the following:
a. Local Anesthetics







2.

Have you ever been hospitalized for any surgical operation or serious illness within the last 3 years?
If yes, please explain:

   b. Antibiotics
c. Sulfa Drugs
d. Barbituates
e. Sedatives
f. Iodine
g. Aspirin
h. Any metals (nickel, mercury, etc)
  i. Latex Rubber
3. Are you taking any medication(s) including non-prescription medicine?
If yes, what medication(s) are you taking?		 j. Other
   
 


           
10. Women only:    
  a. Are you pregnant?
  b. Are you nursing?
c. Are you taking oral contraceptives?
     
4. Have you ever taken Phen-Phen/Redux?
5. Do you use tobacco?
6. Do you use controlled substances?
7. Are you wearing contact lenses?
 
8. Do you have or have you had any of the following?
   YES   NO     YES   NO     YES   NO 
High Blood Pressure Heart Disease Chest Pains
Heart Attack Cardiac Pacemaker Easily Winded
Rhuematic Fever Heart Murmur Stroke
Swollen Ankles Angina Hay Fever Allergies
Fainting/Siezures Frequently Tired Tuberculosis
Asthma Anemia Radiation Therapy
Low Blood Pressure Emphysema Glaucoma
Epilepsy/Convulsions Cancer Recent Weight Loss
Luekemia Arthritis Liver Disease
Diabetes Joint Replacement/Implant Heart Trouble
Kidney Diseases Hepatitus/Jaundice Respiratory Problems
Aids or HIV infection Sexually Transmitted Disease Mitral Valve Prolapse
Thyroid Problem Stomach Troubles/Ulcers Other

Patient Dental History
  Name of Previous Dentist
       Date of Last Exam
  Previous Dentist's Location
       Date of Last Cleaning
   YES   NO     YES   NO 
1. Do your gums bleed while brushing or flossing? 8. Do you have frequent Headaches?
2. Are your teeth sensitive to hot/cold liquids/foods? 9. Do you clich or grind your teeth?
3. Are your teeth sensitive to sweet or sour liquids/foods? 10. Do you bite your lips or cheeks frequently?
4. Do you feel pain to any of your teeth? 11. Have you ever had any difficult extractions in the past?
5. Do you have any sore or lumps in or near your mouth? 12. Have you ever had any prolonged bleeding following extractions?
6. Have you ever had any head, neck, or jaw injuries? 13. Have you ever had any orthodontic treatment?
7. Have you ever experienced any of the following problems in your jaw? 14. Do you wear dentures or partials?
If yes, date of placement:
  a. Clicking      
  b. Pain 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
  c. Difficulty in opening or closing      
  d. Difficulty in Chewing 16. Do you like the appearance of your teeth?
               

Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accuratley asnwered. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Walker/Dr. Brecht to release any information including the diagnosis and the records of any treatment or examination rendered to me or my chold during the period of such Dental care to third party payprs and/or health practitioners. I authorize and request my insurance

company to pay directly to Dr. Walker/Dr. Brecht or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all service rendered on my behalf or my dependants.

X _______________________________