McAlpin Dental Group, P.A. Medical Update Patient Name:______________________________________________________DOB: ____________________ Emergency Contact:________________________________ Emergency Contact Ph. #: ____________________ Do you have or have you had any conditions listed below: Other (Please explain): ________________________________________________________________________
___________________________________________________________________________________________
Have you been treated with Bisphosphonate drugs (such as Fosamax, Boniva, Actonel, Aredia, Skelid and
Didronel)?___________________________________________________________________________________
Have you been to visit a physician since your last dental visit? Please list the name and phone number of your physicians:
1. ________________________________________________________________________________________
2.________________________________________________________________________________________
3. ________________________________________________________________________________________
Please list any medications, dosage & reason that you are taking:
1. _________________________________________
6. _________________________________________
2. _________________________________________
7. _________________________________________
3. _________________________________________
8. _________________________________________
4 _________________________________________
9. _________________________________________
5. _________________________________________
10. ________________________________________
Do you have any allergies or are you allergic to any medications?
If yes please Iist: ___________________________________________________________________________
________________________________________________________________________________________
WOMEN: Are you pregnant? Are you nursing? To the very best of my knowledge, the above information is true.
Patient Signature:_____________________________________________________Date: ____________________
Staff Signature:_______________________________________________________Dr. Initial: ________________
McAlpin Dental Group, P.A. Personal Information Update Patient Name:______________________________________________________DOB: ____________________ Home Address: ______________________________________________________________________________ City:____________________________________State:________Zip: _____________________ Home Phone:__________________________Cell:_________________________Work: ___________________ Email Address: ______________________________________________________________________________ Spouse’s Name:________________________________________ Spouse’s Phone #:_______________________ Emergency Contact (1): _______________________________________________________________________ Emergency Contact (2): _______________________________________________________________________ Dental Insurance Company ID/Group Number: ___________________________________________________ Dental Insurance Company Contact Number: _____________________________________________________
Patient Signature:_____________________________________________________Date: ____________________
Step Therapy Criteria Step Therapy Group Drug Names Step Therapy Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Actos, Actoplus Met, Duetact, Januvia, Janumet, Kombiglyze, Onglyza. Step Therapy Group Drug Names Step Therapy Criteria If the patient has tried two Step 1 drugs, then authorization for
Salto a un nuevo período de la cooperación Por SONG XIA * China hoy 2009,10 *Song Xia es investigadora del Instituto de Estudios de América Latina, subordinado a la Academia de Ciencias Sociales de China. Medio siglo ha transcurrido desde que se firmara el primer acuerdo de cooperación económica y tecnológica entre China y Cuba, en noviembre de 1960, lapso en el que