Bonar Family Dentistry Patient Information Form Patient Name: ________________________________________ Date of Birth:____________________________ MailingAddress:_______________________________________________________________________________
Phone #’s: Home:_____________________ Cell:_________________________ Other:_____________________ Email:__________________ Marital Status: S M D W Other:________ Occupation:______________________ Emergency Contact: ___________________ Relationship to patient:____________ Phone#:________________ Driver’s License:______________ Primary Care Physician: ____________________ Phone #:______________ Insurance Information Patient Employer:________________________ Work Phone:_________________________________________ Primary Dental Insurance:__________________________________________ Phone #:____________________ Subscriber Name:______________________________ Patients Relationship to subscriber:_________________ ID#:_______________________________ Group #:_______________________ Group Name:_______________ Secondary Dental Insurance:_______________________________________ Phone #:_____________________ Subscriber’s Name:_____________________________ Patients Relationship to subscriber:________________ ID#:_____________________________ Group#:___________________________ Group Name: _____________ Responsible Party Person Responsible for bill:____________________________ Home Phone:_____________________________ Mailing Address:____________________________ Social Security:____________________________________ The above information is true to the best of my knowledge. I hereby authorize Paul and Vickie Bonar D.M.D to release any medical or other information necessary to process my claims. I authorize my insurance benefits to be paid directly to Paul and Vickie Bonar D.M.D. for services rendered. I understand that my insurance is billed as a courtesy and that I am responsible for any charges not covered by my insurance. If my balance remains unpaid I understand that I may accrue finance charges based on the amount of time it is left unpaid. Signed:_______________________________________________________________________Date:___________ Bonar Family Dentistry Medical History Answer al questions by circling Yes (Y) or No (N) 8.)ARE YOU USING ANY OF THE FOLLOWING:
2.) Has there been any change in your general health in the past year?
c.) Aspirin or drugs such as Aleve, ibuprofen?
4.) Are you now under a physician's care for a problem?
5.) Have you ever had any serious il nesses, operations or hospitalizations? If so, describe
Y N e.) Steroids (Cortisone, Prednisone's, etc.)?
Al responses are kept confidential 7.) DO YOU HAVE OR HAVE YOU EVER HAD:
a.) Rheumatic Fever or Rheumatic Heart Disease?
Y N i.) Digitalis, Inderal, Nitroglycerin, or other heart drug
j.) Please list any and al medications, over the counter
Y N medications, herbal or holistic remedies vitamins or
c.) Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Mitral Valve Prolapse, Rheumatic Fever,
Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)?
d.) Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Y NChest Pain)?
9.) ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE
e.) Seizures, convulsions, Epilepsy, fainting or dizziness)?
Y N REACTION TO:
f.) Bleeding Disorder, Anemic, bleeding tendency, blood transfusion? Do you bruise easily?
Y N a.) Local anesthesia (Novocain, etc.)?
Y N c.) Sedatives, barbiturates, sulfites?
n.) Implants or artificial joints placed anywhere in your
11.) Is there any past history of alcohol or chemical
body (heart valve, pacemaker, hip, knee) or have you ever Y N dependency or emotional disorder that may affect the care been pre-medicated
o.) Radiation (x-ray) treatment for Cancer?
Y N 12.) Do you use recreational drugs? List
p.) Clicking or popping of jaw joint, pain near ear, difficult opening mouth, grind or clench teeth?
13.) Have you had any serious problems associated with any
14.) Have you or an immediate family member had any
15.) Do you have any other disease, condition, or problem
Y N not listed above that you think the doctors should know
s.) Have you ever been diagnosed with sleep apnea?
t.) Any disease, drug or transplant operation that has
16.) Do you wish to talk to the doctor privately about
u.) Have you had your wisdom teeth removed?
Y N 17.) FOR WOMEN ONLY
a.) Are you pregnant or is there any chance you might be
c.) If you are using oral contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness or oral contraceptives? Therefore, you wil need to use mechanical forms of birth control pil s, after the course of antibiotics or other medication is completed. Please consult your physician for further guidance.
I UNDERSTAND THE IMPORTANCE FOR A TRUTHFUL HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THE BEST POSSIBLE CARE BP / Pulse Bonar Family Dentistry Please list below al prescriptions, over-the-counter medicines, vitamins, herbs, dietary, suppleents, oxygen, inhalers, and homeopathic remedies. Medicine Name When Taken Reasons for Taking (mg, drops, etc) (daily, bendtime, etc.) (blood pressure, diaetes, etc.) Al ergies and Reactions (please describe):
The Marriage of Saint Joseph and the Blessed Virgin Mary Translations of the Catechism of the Catholic Church, paragraph #497 The official version of the Catechism of the Catholic Church is the Latin edition. In the Latin edition, the word “sponsam” is used which means precisely spouse, in the sense of a wife. The English version of the Catechism of the Catholic Church mistakenly u
CAPÍTULO II – Dos princípios e finalidades fundamentais.3 CAPÍTULO III – Do patrimônio e das finanças.5 TÍTULO III – DA ORGANIZAÇÃO GERAL .6 CAPÍTULO II – Do conselho de representantes de turma .7 Seção I – Disposições gerais.8 Seção II – Das atribuições especificas .9 CAPÍTULO I – DA COMISSÃO ELEITORAL .10 TÍTULO V – DAS DISPOSIÇOES ESTATUTÁRIAS .12