South Attleboro Dentist | James M. Phelan, DMD, MAGD | Exquisite Smiles
3 Howarth Ave. South Attleboro, MA 02703
(508) 761-5320
[email protected]
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Thank you for selecting Exquisite Smiles as your dental provider. We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us – we’ll be happy to help.
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Patient Infomation
Name
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First
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Date of Birth
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Email
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Address
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Patient or Parent's Employer
Business Address
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Michigan
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Check Appropriate Box:
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Minor
Single
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Separated
Spouses Name
First
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Spouses Date of Birth
MM
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Spouses Employer
Spouses Work Phone
Are you a student?
*
Full Time
Part Time
No
Name of School/College & City/State
Whom may we Thank for referring you?
First
Last
Emergency Contact:
*
First
Last
Emergency Contact Phone
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Do you have Dental Insurance?
*
Yes
No
Dental Insurance Information
Name of Insured (Subscriber)
*
First
Last
Subscribers Date of Birth
*
Relationship to Patient
*
Employer
*
Work Phone
Address of Employer
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Dental Insurance Company
*
Dental Insurance Company Group #
*
Dental Insurance Company ID #
*
Dental Insurance Company Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Company Phone #
*
Do you have Secondary Dental Insurance?
*
Yes
No
Name of Insured (Secondary)
First
Last
Relationship to Patient
Employer
Work Phone
Address of Employer
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Secondary Dental Insurance Company
Secondary Dental Insurance Company Group #
Secondary Dental Insurance Company ID #
Secondary Dental Insurance Company Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Current Physicians's Name
*
First
Last
Date of Last Physical
*
MM
DD
YYYY
Physician's Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Physician's Phone
*
Are you in good health?
*
Yes
No
Has there been any changes in your general health within the past year?
*
Yes
No
Have you had any serious illness, operation or been hospitalized in the past 5 years?
*
Yes
No
If so, what was the illness or problem?
Any heart ailments
*
Yes
No
Heart murmur
*
Yes
No
High Blood Pressure
*
Yes
No
Low Blood Pressure
*
Yes
No
Prosthetic joint replacement
*
Yes
No
Radiation treatments
*
Yes
No
Psychiatric Care/emotional problems
*
Yes
No
Tonsillitis
*
Yes
No
Ulcer/colitis/acid reflux
*
Yes
No
Allergy
*
Yes
No
Sinus Trouble
*
Yes
No
Asthma or hay fever
*
Yes
No
Fainting spells/seizures/epilepsy
*
Yes
No
Kidney trouble
*
Yes
No
Diabetes
*
Yes
No
Hepatitis, B or C/ liver disease
*
Yes
No
AIDS or HIV infection
*
Yes
No
Herpes Simplex I or II
*
Yes
No
History of STD and/or Human Papilloma Virus (HPV)
*
Yes
No
Thyroid problems
*
Yes
No
Respiratory problems, emphysema, bronchitis, etc
*
Yes
No
Tuberculosis
*
Yes
No
Persistent cough or cough that produces blood
*
Yes
No
Persistent swollen glands in neck
*
Yes
No
Problems of the immune system
*
Yes
No
Have you ever been treated for tumor or growth?
*
Yes
No
Have you had abnormal bleeding?
*
Yes
No
Have you ever required a blood transfusion?
*
Yes
No
Do you have any blood disorder such as anemia?
*
Yes
No
Do you smoke or use tobacco products now or have you in the past?
*
Yes
No
How much? When?
Do you use alcohol?
*
Yes
No
How much? When?
ARE YOU ALLERGIC OR HAVE YOU HAD A REACTION TO:
Local anesthetics
*
Yes
No
Penicillin or other Antibiotics
*
Yes
No
Sulfa Drugs
*
Yes
No
Barbiturates, sedatives, sleeping pills
*
Yes
No
Aspirin
*
Yes
No
Iodine
*
Yes
No
Codeine or other narcotics
*
Yes
No
Latex
*
Yes
No
Other:
Gender
*
Female
Male
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking birth control?
Yes
No
List all prescription and over the counter medications you are taking.
*
Do you wear any removable dental appliances?
*
Yes
No
Do you have any family history of oral cancer?
*
Yes
No
Do you have any specific dental concerns? Please elaborate
*
What are your goals for your oral health over the next 10+ years?
*
Acknowledgement
*
I certify that I have read and understand the above. I acknowledge that my questions, if any about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Please Type Your Name As Your Signature
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Or PARENT OR GUARDIAN IF PATIENT IS A MINOR
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