PATIENT INFORMATION Name Social Security # -- Address City    State    Zip  Phone () Cell Phone () Email Address Birth Date // Example 07/08/1959 Marital Status Single  Married  Widowed  Separated  Divorced  Employer Occupation Work Phone () Whom may we thank for referring you? HEALTH AND DENTAL HISTORY Physician's name Physician's Phone Date of last visit // Example 07/08/1959 Have you had any serious illnesses or operations? Yes No If yes, please describe Are you currently under physician care? Yes No If yes, please describe Have you ever had any cosmetic procedures? Yes No Women: Are you pregnant? Yes No Nursing? Yes No Taking Birth control pills? Yes No Check if you have had any of the following: Heart Problems High Blood Pressure Heart Murmur Stroke Mitral Valve Prolapse Diabetes Artificial Heart Valve Epilepsy/Seizures Pacemaker Anemia Asthma Circulatory Problems Respiratory Disease Liver Disease Hepatitis Kidney Disease AIDS/HIV Artificial Joints Abnormal Bleeding Tuberculosis Rheumatic/Scarlet fever Chemical Dependency Tobacco Habit Venereal Disease Herpes Neurological Disorders Psychiatric/Psychological DENTAL CONCERNS: Headaches Jaw Pain Facial Pain Jaw Popping Neck Ache Clenching Bells Palsy Grinding Loose Teeth Limited Opening Tingling in fingers Difficulty Swallowing Insomnia/frequent waking Gums Bleed Floss shreds when using Food catches between teeth Congested Ears Ringing Ears Dizziness Sensitive Teeth Difficulty Chewing Trigeminal Neuralgia Halitosis (bad breath) Chew Tobacco Allergies to medication or Latex Signature

By typing my name into the signature box above, I authorize Dr. Overton to administer medications and perform diagnostic and photographic procedures as necessary for proper dental care. I grant the right to the dentist to release my dental /medical histories and other information about my dental treatment to third party payers and other health professionals.