Dr Colpitts Wellness Center (918) 477-9000 Fax (918) 477-9056 PATIENT INFORMATION: 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: Name: Relationship: 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) INSURANCE INFORMATION
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:_______________________ Telephone:_________________________ 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?
Adult dose Pediatric dose Comments Contraindications/ Precautions travel, then daily and for 7 with severe renal impairment should be taken with food women, and women only in areas chloroquine- sensitive P. falciparum retinopathy not seen in malaria prophy doses same day of the until for 4 SE: gastrointestinal only in areas chloroquine- sensitive P.
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