New Patient Forms Oct 04, 2023 Thank you for choosing Off-Island Dental to assist you with your dental needs. Name (Required) Date of Birth (Required) Sex (Required) If minor, name of legal guardian Home Phone Mobile Phone Work Phone Email Address(Required) Mailing Address(Required) City (Required) State (Required) Zip (Required) Employer Whom may we thank for referring you to our office? INSURANCE INFORMATION: Covered by dental insurance? YesNo Your SS# : Member ID# Dental Insurance Co. Group number Claims Address Covered by spouse’s insurance? —Please choose an option—YesNo Spouse’s Name Spouse's dental insurance company Group number Spouse's birthday SS# or Member ID# MEDICAL HEALTH HISTORY Do you have, or have you had any of the following? (Please check any that apply) Are you required to Pre-medicate before any dental treatment ? Blood Problems (Anemia)Blood transfusionHeart problemsHeart murmur, mitral valve prolapse, heart defectHeart PacemakerStrokeBone or joint problemsArtificial joint or valvesHigh or low blood pressure (circle one)Tuberculosis or other lung problemsKidney diseaseHepatitis, jaundice or other liver diseasesDiabetes TYPE 1 or TYPE 2Epilepsy or Neurological disordersThyroid problemsArthritisHerpes or cold soresAIDS or HIV positiveCancer/TumorAbnormal bleeding after any surgery (heavy bleeder)Hayfever or sinus troubleAllergiesAsthma Are you allergic to, or have you reacted adversely to any of the following? LatexPenicillin or other antibioticsLocal anestheticsCodeine or other narcoticsSulfa drugsBarbiturates, sedatives, or sleeping pillsAspirinOther Other Are you taking any of the following? AspirinAnticoagulants (blood thinners e.g. Coumadin)Antibiotics or sulfa drugsHigh blood pressure medicineAntidepressants or tranquilizersInsulin other diabetes drugsNitroglycerinCortisone or other steroidsOsteoporosis (bone density) medicineNatural supplementsOther Other Women: Are your pregnant or plant to become pregnant YesNo Taking hormones or contraceptives YesNo Do you smoke,vape or use tobacco? YesNo Name of your primary medical physician: Phone number (Required) I have read and understand the Fnancial policy of Off Island Dental and agree to be bound by its terms and conditions. Acknowledgement of Receipt of HIPAA Policies and Procedures.