Call Us: (704) 375-4252

General Patient Information

Yes No
Single Married Divorced Widowed Seperated Domestic Partner
E-mail Cell Phone Work Phone Home Phone

Insurance - Primary

Insurance - Secondary

Nearest relative not living with you:

Medical History

Yes No
Yes No
Yes No
Yes No
Yes No
Do you have any of these conditions? Yes No
Abnormal Bleeding
Alcohol Abuse
Angina Pectoris
Artificial Heart Valve
Blood Transfusion
Congenital Heart Defect
Difficulty Breathing
Drug Abuse
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Sexually Transmitted Disease
Sickle Cell Disease
Sinus Problems
Thyroid Problems
If Female, do you have any of these conditions? Yes No
Abnormal Bleeding
Alcohol Abuse

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Corey L. Plaster, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Responsible Party Signature: ___________________________________ Date:______________
(The signature above will be physically signed when at dental office.)

Dental History

Good Fair Poor
Please answer the following Yes No
Do you require antibiotics before dental treatment?
Are you currently in pain?
Do you now or have you had any pain/discomfort in your jaw joint?
Are you aware of clenching or grinding your teeth?
Does it hurt when you chew or open wide to take a bite?
Do you have any jaw symptoms or headaches upon waking up in the morning?
Do you have pain in the face, cheeks, jaw, joints, throat or temples?
Do you like your smile?
Is there anything you would like to change about your smile?
Are you happy with the color of your teeth?
Have you ever had gum disease?
Do your gums bleed?
Have you ever had a deep cleaning or scaling and root planing?
Please answer the following Yes No
Are your teeth sensitive to heat, cold or anything else?
Do you take fluoride supplements?
Have you ever had a serious/difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences?
Are you apprehensive about dental treatment?
Do you gag easily?