Brian E. Hornberger D.D.S.. M.S.
(925) 753-5810
Email: endo2@sbcglobal.net
Page 1 of 4: Patient History Information
Name
SSN
Kaiser #
Gender
Male
Female
D.O.B.
Address
Apt#
City
Zip
Home # (xxx)xxx-xxxx
Cell # (xxx)xxx-xxxx
Work #
Email
Referring Dental Office
Employer Name
Employer Address
City & Zip
Emergency Contact
Emergency Phone #
Physician's Name
Physician's Phone #
If Student, School Name
Full Time
Part Time
If Minor, Parent/Guardian
Patient Medical History
Are you under any medical treatment at this time?
Yes
No
Within the past 5 years have you been hospitalized for any surgical operation or serious illness?
Yes
No
Are you currently taking any medication?
Yes
No
In case of medication needing to be prescribed. Which pharmacy do you prefer?
Do you use controlled substances?
Yes
No
Have you ever taken phen-phen?
Yes
No
Do you take a blood thinning medication?
Yes
No
Do you use tobacco?
Yes
No
Do you take insulin?
Yes
No
Have you ever taken bisphosphonates?
Yes
No
Are you allergic to any of the following?
Latex Rubber
Yes
No
Sulfa Drugs
Yes
No
Aspirin/Ibuprofen
Yes
No
Barbiturates(for insomnia, seizures, convulsions, anxiety)
Yes
No
Local Anesthetic
Yes
No
Sedatives
Yes
No
Metals
Yes
No
Penicillin
Yes
No
Iodine
Yes
No
Other Antibiotics
Other
Do you have a history of the following?
Heart Attack
Yes
No
Heart Murmur
Yes
No
Mitral Valve Prolapse
Yes
No
Sexually Transmitted Disease
Yes
No
Heart Disease
Yes
No
Cardiac Pacemaker
Yes
No
Joint Replacement/Implant
Yes
No
Diabetes
Yes
No
AIDS/HIV
Yes
No
Hepatitis
Yes
No
Jaundice
Yes
No
Asthma
Yes
No
Anemia
Yes
No
Angina
Yes
No
Emphysema
Yes
No
Cancer
Yes
No
Stroke
Yes
No
Liver Disease
Yes
No
Thyroid Problems
Yes
No
Radiation Therapy
Yes
No
Tuberculosis
Yes
No
Respiratory Problems
Yes
No
Fainting Seizures
Yes
No
Epilepsy/Convulsions
Yes
No
Kidney Disease
Yes
No
Stomach Ulcers
Yes
No
Blood Pressure
High
Normal
Low
Other
*Women Only
Are you or might you be pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking oral contraceptives?
Yes
No
Method Of Payment
Patient Co-Payment must be paid in full at the time of treatment. How will you be paying today? ** NO CHECKS **
To apply for Care Credit
click here
.
Cash
Credit Card
Care Credit
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. I understand that providing false information can be dangerous to my health. I authorize the dentist to release information including diagnosis and records of treatment rendered to me or dependent to a third party payee &/or health practitioners. I authorize and request my insurance company to pay directly to Dr. Hornberger/East County Endodontics.
I understand that the insurance information provided to me is an estimate only and not a guarantee of payment. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
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