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2 Locations in Huntington Beach

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- Across 5 Points Plaza
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Patient Information & History Form

Please complete all sections as accurately as possible. If you have questions, contact our team.

Patient Information

Name *

Birthdate

Home Phone

Street Address

City

State/Prov.

Zip / P.C.

Email

Cell Phone

Check Appropriate Box

Minor Single Married Divorced Widowed Separated

If Student, Name of School/College

School City

Full / Part Time

Full Time Part Time

Patient or Parent/Guardian’s Employer

Work Phone

Employer Street Address

City

State/Prov.

Zip / P.C.

Spouse or Parent/Guardian’s Name

Employer

Work Phone

Whom may we thank for referring you?

Emergency Contact (Name)

Emergency Contact Phone

Responsible Party / Person Responsible for This Account

Name of Person Responsible

Relationship to Patient

Address

Home Phone

Cell Phone

Email

Driver’s License #

Birthdate

Financial Institution

SS# / SIN

Employer

Work Phone

Is this person currently a patient in our office? Yes No

Payment Preference

Cash Credit Card VISA MasterCard I wish to discuss the office’s payment policy

Insurance Information (Primary)

Name of Insured

Relationship to Patient

Birthdate

SS# / SIN

Date Employed

Union or Local #

Name of Employer

Work Phone

Employer Address

City

State/Prov.

Zip / P.C.

Insurance Company

Group #

Policy/ID #

Insurance Co. Address

City

State/Prov.

Zip / P.C.

Do you have any additional insurance? Yes No

Additional Insurance (If Yes)

Name of Insured

Relationship to Patient

Birthdate

SS# / SIN

Date Employed

Union or Local #

Name of Employer

Work Phone

Employer Address

City

State/Prov.

Zip / P.C.

Insurance Company

Group #

Policy/ID #

Insurance Co. Address

City

State/Prov.

Zip / P.C.

Patient Medical History

Physician

Office Phone

Date of Last Exam

1. Are you under medical treatment now?

Yes No

2. Have you been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain:

3. Are you taking any medication(s), including non-prescription medicine?

Yes No

If yes, what medication(s) are you taking?

4. Have you had a serious head, neck or jaw injury?

Yes No

5. Have you ever taken Fen-Phen/Redux?

Yes No

6. Have you taken Fosamax, Boniva, Actonel or any osteoporosis/cancer medications containing bisphosphonates?

Yes No

7. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?

Yes No

8. Do you use tobacco?

Yes No

9. Do you use controlled substances?

Yes No

10. Do you have or have you had any of the following? (Select all that apply)

AIDS/HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Frequently Tired Genital Herpes Glaucoma Hay Fever/Allergies Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Joint Replacement Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Swollen Ankles Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice

Other (please list)

11. Are you wearing contact lenses?

Yes No

13. Persistent cough or throat clearing > 3 weeks (not associated with known illness)?

Yes No

12. Allergies / Reactions (Select all that apply)

Local Anesthetics (e.g. Novocain) Penicillin / other Antibiotics Sulfa Drugs Barbiturates Sedatives Iodine Aspirin Metals (nickel/mercury etc.) Latex Rubber

Other (please list)

14. Women Only

a) Are you pregnant or think you may be pregnant?

Yes No

b) Are you nursing?

Yes No

c) Are you taking oral contraceptives?

Yes No

Patient Dental History

Name of Previous Dentist and Location

Date of Last Exam

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Jaw problems (check all that apply)

Clicking Pain (joint, ear, side of face) Difficulty opening/closing Difficulty chewing

7. Do you have frequent headaches?

Yes No

8. Do you clench or grind your teeth?

Yes No

9. Do you bite your lips or cheeks frequently?

Yes No

10. Difficult extractions in the past?

Yes No

11. Prolonged bleeding following extractions?

Yes No

12. Have you had orthodontic treatment?

Yes No

13. Do you wear dentures or partials?

Yes No

If yes, date of placement

14. Have you received oral hygiene instructions for care of your teeth and gums?

Yes No

15. Do you like your smile?

Yes No

Authorization and Release

By signing below, you certify that the information is accurate and authorize release of information to third-party payors and/or health practitioners, and authorize insurance payments to be made directly to the provider. :contentReference[oaicite:2]{index=2}

Signature of Patient (or Parent/Guardian if minor) – typed

Optional: Replace with drawn e-signature if you want.

Date

Signature – typed

Date

Doctor’s Comments

Two convenient locations in Huntington Beach, CA.

Across 5 Points Plaza

18586 Main St,
Huntington Beach, CA 92648
Google Map

(714) 842-5561

Hours & Direction

Downtown Location

305 Orange Ave. #C
Huntington Beach, CA 92648
Google Map

(714) 374-1833

Hours & Direction

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