Dr Colpitts Wellness Center
(918) 477-9000 Fax (918) 477-9056
Today’s date:
Preferred Name:
Male ____ Female ____
Single ___ Married ___ Divorced ___ Widowed ____ Minor ______
Date of Birth:____/_____/______ Social Security #:_______________________
Home address: ________________________________City: ____________ St: ____ Zip:____________
E-mail address:
Home phone: ___________________Work phone: ______________Cell phone: ________________
Place of Employment:
Last dental appt: ________For what? _______ ____________________________ _______________
Major complaint or reason for visit: _________________________________________________
Current x-rays or diagnostic information: _______________________________ Date: ____________
Have you been seen for this condition:____ Date:______ What was done:_____________________
Major complaint or reason for referral: _________________________________________________
Cleanings per year: ______ Date of most recent: ________________
How did you find us?___________________________________________________________________
In case of emergency please notify:
In consideration of the services rendered to me by this office, I am obligated to pay said office in accordance with its credit terms and policy. All today’s procedures are expected to be paid in full: credit, check, cash (ask about Care Credit)
To be completed if you have Dental Insurance—Medicare and Health insurance do not pay for our services.
Please give your dental card to the front desk person or have a copy front and back with you
Primary Insurance
Name of person that carries coverage: _________________________________D.O.B.___________

Employer: ________________________________________________ Bus Phone: _______________
Name of Insurance Co.:_____________________________Address:___________________________
Policy or Group #:_______________ Social Security#:_____________________________________
All insurance re-imbursements will be paid directly to you
Assignment & Release: I authorize the dentist to release any information required for this claim
.Patient’s signature: _____________________________________________________
Medical History
If you have current x-rays or pertinent information please give it to the front desk person
Your Physician:____________________MD or DO Address:_______________________
Please check the following if it applies to you:
____ Ever had or have Hepatitis Type:____ When?_________________
____ Epilepsy
____ Rheumatic fever
____ Scarlet fever
____ Heart murmur or mitral-valve prolapse
____ High Blood pressure
____ Have you been told (by physician) to take an antibiotic prior to a dental appointment
____ Kidney or liver disorders or disease
____ Diabetes Type: _____ Insulin dependent:______ Date Diagnosed:______
____ Cancer Type :________________ Date of Chemo:_______ or Radiation:______
____ TIA or Stroke
____ Heart trouble Heart attack: ____ Stent:_____ Date:_________
____ Stomach ulcer
____ Thyroid disorder
____ Smoking How much per day:_____ How many years: _______Quit?_______
____ Prolong bleeding due to procedures or a slight cut
____ Immune deficiency (AIDS or HIV)
____ Psychiatric treatment or emotional problems
If you are a female: _____ pregnant _____ taking birth control pills _____ hormones
Allergies or reaction to:
____ penicillin ____aspirin _____ erythromycin ____tetracycline ____codeine
____ sedative ____ dental anesthetic ____ latex
____any other medication describe:__________________________________________
Any type of disability; please describe:________________________________________
List of current prescription medications you are now taking:______________________
Are you on a detox regime?______ What:______________________________________
Any other medical conditions you have that were not listed above __________________
2. Do you believe there is a connection between YOUR MOUTH and your That infections in the mouth affect your OVERALL HEALTH? That MERCURY and metals affect your OVERALL HEALTH? 3. What would you like your mouth to look like in 6 months? What would you like your mouth to look like in 5 years? 4. If time and money were not an issue, what would you do for the health of your 5. Do you like the way your mouth looks (shade or color and shape)? 6. What is your biggest fear concerning your teeth?



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VERNON B. WILLIAMS, M.D. 6801 Park Terrace. Los Angeles, CA 90045 EDUCATION University of Michigan, Ann Arbor, MI Inteflex Accelerated Pre-Medical/Medical Program POST-GRADUATE TRAINING 1996 - 1997 Johns Hopkins Hospital, Baltimore, MD Department of Anesthesiology and Critical Care 1993 - 1996 University of Maryland Medical Center, Baltimore, MD 1

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