PATIENT NO.: (for office use only) - Dental Implants

1 PATIENT NO.:( for office use only )I , _____ , give ClearChoice Dental Implant Center permission to leave information pertaining to: Appointment Information Treatment Information Health Care Financing Information Referral Information Test ResultsPlease consider carefully where we can leave voicemail messages and whom you want to have access to your medical Information:Please complete all the information and select which option you Daytime phone number (7am 5pm): _____ M No VoicemailM Evening phone number (after 5pm): _____ M No VoicemailM Weekend phone number (Sat & Sun): _____ M No Voicemail M Email: _____My medical care may be discussed with the person(s) listed below:_____Relationship _____Relationship _____Is someone accompanying you?

2 Yes _____No Name and Relation: _____Signature of PATIENT /Guardian _____ Date _____Please complete all information on this initial permission for WORK TO BE DONE:Consult _____initialsi-CAT _____initialsPanoramic x-ray _____initialsFull Legal Name (Please Print First, Middle and Last) Male/FemaleResidential Address City State ZIPDate of Birth Height Weight Age Home Phone Cell PhoneOccupation EmployerBusiness Phone EmailDENTAL HISTORYDo you have any Major Medical Problems?

3 Yes NoPlease explain: _____Is there any chance you could be pregnant? ____Yes ____NoAre you currently taking, or have you ever taken, any Bisphosphonates or other medication for osteoporosis? Yes NoPlease list current or past prescribed Bisphosphonate drug(s) for example: Actonel, Boniva, Fosamax, Skelid:_____Have you ever been treated for periodontal gum disease? ____Yes NoDo you have a family dentist? Yes ____NoDentist s name: _____Last visit: _____What is your main Dental concern today? _____How is your current Dental condition affecting you? _____How would treating your Dental condition change your life?

4 _____How soon would you like to start your Dental treatment? _____Please complete all information on this NO.:( for office use only )