• Welcome to our practice. We look forward to providing you with excellent care in dentistry and facial aesthetics. Please fill out the following information so we may best serve you.

    Dr. Carolina Borgenicht • Dr. Santiago Lopez

Patient Information

  • Today's Date
  • First Name
  • Last Name
  • Home Address
  • City
  • State
  • Country
  • Age
  • Date of Birth (mm/dd/yy)
  • Sex
  • Male Female
  • Marital Status
  • Single Married Widowed Separated Divorced
  • Social Security #
  • Email Address
  • Home PH #
  • Cell PH #
  • Work PH #
  • Employer
  • Occupation
  • Work Address
  • City
  • State
  • Zip
  • Country
  • How Did You Hear About Us?
  • Referral:
  • Who may we thank for recommending us?
  •  
  • Online:
  • Google Facebook
  • other online source
  •  
  • Event:
  • Seminar Bridal Show Spa Event School Event
  •  
  • Mailing:
  • Magazine Postcard

Emergency Contact

  • Name of person we should contact in case of emergency
  • Relationship
  • Home PH #
  • Cell PH #

Billing Information

  • Person Responsible for Account
  • Self Parent/Guardian
  • Billing Address (if different from patient's address)
  • City
  • State
  • Zip
  • Country
  • Dental Insurance?
  • Yes No
  • Insurance Company
  • Phone #
  • Name Of Insured
  • Self Other
  • Relationship
  • Date of Birth (mm/dd/yy)
  • Social Security
  • Patient Full Name
  • Patient Signature
DEN-NP
Page 1

 

Your Medical Information

  • Name of primary doctor
  • Phone Number
  • Are you under a physician's care for any medical condition?
  • Yes No
  • if yes, please explain:
  • Have you ever been hospitalized or had a major operation?
  • Yes No
  • if yes, please explain:
  • Please list all the medications, pills, or drugs that you are taking
  • Are you allergic to any of the following?
  • Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs
    Local Anesthetics Other Allergies
  • Have taken Phen-Fen or Redux?
  • Yes No
  • Have you taken Fosamax, Boniva, or Actonel?
  • Yes No
  • Do you drink alcohol?
  • Yes No
  • if yes, how much/how often?
  • Do you smoke or use tobacco?
  • Yes No
  • if yes, how much/how often?
  • WOMEN ONLY:
  • Are you pregnant or trying to get pregnant?
  • Yes No
  • if pregnant, how many weeks?
  • Are you taking oral contraceptives?
  • Yes No
  • Are you nursing?
  • Yes No
  • In order to safely treat you and make proper diagnoses, it is important that we know your medical conditions.
  • Do you have, or have you had, any of the following?
  • Yes No Yes No Yes No Yes No
    AIDS/HIV Positive
    Cortisone Medicine
    Hepatitis A
    Renal Dialysis
    Alzheimer's Disease
    Diabetes
    Hepatitis B or C
    Rheumatic Fever
    Anaphylaxis
    Drug Addiction
    Herpes
    Rheumatism
    Anemia
    Easily Wineded
    High Blood Press
    Scarlet Fever
    Angina
    Emphysema
    High Cholesterol
    Shingles
    Arthritis/Gout
    Epilepsy or Seizures
    Hives or Rash
    Sickle Cell Disease
    Artificial Heart Valve
    Excessive Bleeding
    Hypoglycemia
    Sinus Trouble
    Artificial Joint
    Excessive Thirst
    Irregular Heartbeat
    Spina Bifida
    Asthma
    Fainting/Dizziness
    Kidney Problems
    Stomach/GI Disease
    Blood Disease
    Frequent Cough
    Leukemia
    Stroke
    Blood Transfusion
    Frequent Diarrhea
    Liver Disease
    Swelling of Limbs
    Breathing Problem
    Frequent Headaches
    Low Blood Pressure
    Thyroid Disease
    Bruise Easily
    Genital Herpes
    Lung Disease
    Tonsillitis
    Cancer
    Glaucoma
    Mitral Valve Prolapse
    Tuberculosis
    Chemotherapy
    Hay Fever
    Osteoporosis
    Tumors of Growth
    Chest Pain
    Heart Attack/Failure
    Pain in Jaw Joints
    Ulcers
    Cold Sores/Fever Blister
    Heart Murmur
    Parathyroid Disease
    Venereal Disease
    Congenital Hear Disorder
    Heart Pace Maker
    Psychiatric Care
    Yellow Jaundice
    Convulsions
    Heart Trouble/Disease
    Radia on Treatments
  • Have you ever had any serious illness not listed above?
  • Yes No
  • if yes, please explain
  • Do you need to be premedicated before dental treatment?
  • Yes No
  • if yes, please explain
  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that probiding inaccurate information can be dangerous to the health of the patient. it is my responsibility to inform this office of any changes in my medical status.
  • Signature of Patient (or Parent/Guardian)
  • Date
FAC/DEN-NP
Page 2

PLEASE TELL US ABOUT YOUR SMILE

  • What is the primary reason for your visit today?
  • When was your last dental cleaning?
  • When was your last dental x-ray?
  • Do you brush regularly?
    Yes No
  • Do you floss regularly?
    Yes No
  • Have you had a bad reaction at the dentist in the past?
  • Yes No
  • if yes, to what?
  • Your anxiety level at the dentist is:
  • Low Medium High Very High
  • How happy are you with your smile?
  • It's Just OK Very Happy Could Be Nicer
  • Please answer every question below:
  • Comments:
  • Do your gums bleed when brushing/flossing?
  • Yes No
  • Are you currently experiencing dental pain?
  • Yes No
  • Do you grind or clench your teeth?
  • Yes No
  • Do you currently wear a nightguard when you sleep?
  • Yes No
  • Do you get frequent headaches?
  • Yes No
  • Do you suffer from TMJ symptoms or pain?
  • Yes No
  • Are you intrested in implants to replace missing teeth?
  • Yes No
  • Are you intrested in whitening your teeth?
  • Yes No
  • Are you intrested in straightening your teeth?
  • Yes No
  • Are you interested in fuller lips?
  • Yes No
  • Are you interested in improving the lines/wrinkles around your mouth?
  • Yes No
  • Is there something about your smile that you would like to improve?
  • I, the undersigned (patient or legally responsible party), authorize dental treatment to be rendered by the dentist and his staff, and I assume all financial responsibility for treatment given, services rendered and all associated costs incurred as a result of my treatment. I acknowledge that all the information contained herein is true and correct and give my permission to verify any of the information provided. I, the undersigned (patient or legally responsible party), have reviewed the HIPAA Privacy Policy Notice available in the office of Elite Dental & Aesthetics.
  • SIGNATURE OF PATIENT (or Parent/Guardian):
  • Date
DEN-NP
Page 3


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