Bonar Family Dentistry
Patient Information Form
Patient Name: ________________________________________ Date of Birth:____________________________
Phone #’s: Home:_____________________ Cell:_________________________ Other:_____________________
Email:__________________ Marital Status: S M D W Other:________ Occupation:______________________
Emergency Contact: ___________________ Relationship to patient:____________ Phone#:________________
Driver’s License:______________ Primary Care Physician: ____________________ Phone #:______________
Patient Employer:________________________ Work Phone:_________________________________________
Primary Dental Insurance:__________________________________________ Phone #:____________________
Subscriber Name:______________________________ Patients Relationship to subscriber:_________________
ID#:_______________________________ Group #:_______________________ Group Name:_______________
Secondary Dental Insurance:_______________________________________ Phone #:_____________________
Subscriber’s Name:_____________________________ Patients Relationship to subscriber:________________
ID#:_____________________________ Group#:___________________________ Group Name: _____________
Person Responsible for bill:____________________________ Home Phone:_____________________________
Mailing Address:____________________________ Social Security:____________________________________
The above information is true to the best of my knowledge. I hereby authorize Paul and Vickie Bonar D.M.D to release any medical or
other information necessary to process my claims. I authorize my insurance benefits to be paid directly to Paul and Vickie Bonar D.M.D.
for services rendered. I understand that my insurance is billed as a courtesy and that I am responsible for any charges not covered by my
insurance. If my balance remains unpaid I understand that I may accrue finance charges based on the amount of time it is left unpaid.
Bonar Family Dentistry
Answer al questions by circling Yes (Y) or No (N)
8.)ARE YOU USING ANY OF THE FOLLOWING:
2.) Has there been any change in your general health in the past year?
c.) Aspirin or drugs such as Aleve, ibuprofen?
4.) Are you now under a physician's care for a problem?
5.) Have you ever had any serious il nesses, operations or hospitalizations? If so, describe
Y N e.) Steroids (Cortisone, Prednisone's, etc.)?
Al responses are kept confidential
7.) DO YOU HAVE OR HAVE YOU EVER HAD:
a.) Rheumatic Fever or Rheumatic Heart Disease?
Y N i.) Digitalis, Inderal, Nitroglycerin, or other heart drug
j.) Please list any and al medications, over the counter
Y N medications, herbal or holistic remedies vitamins or
c.) Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Mitral Valve Prolapse, Rheumatic Fever,
Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)?
d.) Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Y NChest Pain)?
9.) ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE
e.) Seizures, convulsions, Epilepsy, fainting or dizziness)?
Y N REACTION TO:
f.) Bleeding Disorder, Anemic, bleeding tendency, blood transfusion? Do you bruise easily?
Y N a.) Local anesthesia (Novocain, etc.)?
Y N c.) Sedatives, barbiturates, sulfites?
n.) Implants or artificial joints placed anywhere in your
11.) Is there any past history of alcohol or chemical
body (heart valve, pacemaker, hip, knee) or have you ever Y N dependency or emotional disorder that may affect the care been pre-medicated
o.) Radiation (x-ray) treatment for Cancer?
Y N 12.) Do you use recreational drugs? List
p.) Clicking or popping of jaw joint, pain near ear, difficult opening mouth, grind or clench teeth?
13.) Have you had any serious problems associated with any
14.) Have you or an immediate family member had any
15.) Do you have any other disease, condition, or problem
Y N not listed above that you think the doctors should know
s.) Have you ever been diagnosed with sleep apnea?
t.) Any disease, drug or transplant operation that has
16.) Do you wish to talk to the doctor privately about
u.) Have you had your wisdom teeth removed?
Y N 17.) FOR WOMEN ONLY
a.) Are you pregnant or is there any chance you might be
c.) If you are using oral contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness or oral contraceptives? Therefore, you wil need to use mechanical forms of birth control pil s, after the course of antibiotics or other medication is completed. Please consult your physician for further guidance.
I UNDERSTAND THE IMPORTANCE FOR A TRUTHFUL HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THE BEST
BP / Pulse
Bonar Family Dentistry
Please list below al prescriptions, over-the-counter medicines, vitamins, herbs, dietary, suppleents,
oxygen, inhalers, and homeopathic remedies.
Reasons for Taking
(mg, drops, etc) (daily, bendtime, etc.)
(blood pressure, diaetes, etc.)
Al ergies and Reactions (please describe):
DIREZIONE CENTRALE NORMATIVA E CONTENZIOSO Oggetto: Istanza d'interpello. Articolo 167, comma 5, del D.P.R. 22 dicembre 1986, n. 917. Testo: Il soggetto controllante in oggetto ha richiesto la disapplicazione delle disposizioni contenute negli articoli 167 del Testo Unico delle imposte sui redditi, approvato con DPR 22 dicembre 1986, n. 917 (TUIR) in relazione ai redditi derivanti dalla soc
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