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Name ________________________________________________________________________ Birthdate ______________ Sex: □ Male □ Female Address _______________________________________________________________________ Employer _________________________________________________ City____________________________________________Zip Code ______________________ Occupation ______________________ SS# _____________________ Mailing Address (if different) ___________________________________________________ Are you covered by insurance? □ Yes □ No Home Phone ________________________ Work Phone_______________________________ Who may we thank for sending you? _________________________ Driver’s License Number _______________________________________________________ Email Address _____________________________________________ Do you have or have you had any of the following: Explanation of above answers _________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Reason for today’s visit _______________________________________________________________________________________________________________________ How long since last medical exam?__________________________________ How long since last dental cleaning/exam? ____________________________________ List any medications you are taking ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Have you ever taken: Phen-Fen?_____________ Fosamax/Actonel (for osteoporosis)?________________ IV Bisphosphanates (for cancer)? _________________ Have you experienced any allergic or unusual reaction to: Penicillin_______ Aspirin_______ Codeine_______ Dental Anesthetic_______ Other ___________ Physician name__________________________________________________ Physician phone _____________________________________________________________ Do you or have you had any illnesses or health problems not listed above that we should know about? _________________________________________________ WOMEN: Are you or could you be pregnant?________ If yes, which trimester? _____________________________________________________________________ Are you apprehensive about dental treatment? Have you had negative dental experiences before? Are you happy with the appearance of your teeth? Permit for treatment and surgical care: I hereby grant permission to the staff of Jacy C. Nelson, DDS, PS to employ such established treatments and therapy as may be deemed professionally necessary or advisable. For most dental procedures, local anesthetic is administered. Risks involved may include the following: Heart palpation, allergic reaction, hemotoma, parasthesia and/or drug cross reaction. FINANCIAL AGREEMENT: All charges for services and treatment will be paid upon completion of appointment. All outstanding balances over 90 days shall accrue interest at the rate of 1% per month. IF INSURANCE IS INVOLVED: I hereby authorize payment directly to Jacy C. Nelson, DDS, PS otherwise payable to me. I hereby certify that the above information is true and correct to the best of my knowledge. PATIENT/GUARDIAN/GUARANTOR’S SIGNATURE___________________________________________________________________DATE ________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Source: http://www.jacynelsondds.com/files/Health_History_Form_2.pdf

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Catherine Street Medical Centre 18 Catherine Street, Waterford www.catherinestreetmedicalcentre.com Phone:051-875338/877317 Fax: 051-878265 Dr. Tony Lee M.R.C.G.P. M.I.C.G.P. D.Obs. D.C.H. Dip. H.S.W. D.C.H. MC 06090 Dr. Aine Hennigan D.Obs.,D.Psych.,D.Derm,M.I.C.G.P., L.F.O.M. MC 17496 Dr. Sarah O’Brien M.B. , B.Ch., M.R.C.P.I., M.I.C.G.P., D.C.H. MC 22900

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