(314) 487-0333 6076 Telegraph Road, St. Louis, MO 63129 oakdc.com rev. 6/14

ADULT FORM

WELCOME The benefits of a healthy, happy smile are immeasurable. Our

Please fill out this form completely.

First:_________________ Last:___________________ M.I.____

Birthday:___/___/______ Age:_____ SSN:_____-____-______

Address:__________________________________ Apt.______

City:_____________________State:__________ ZIP:_________

Email:_______________________________________________

Mobile #:( )____-_______

Home #:( )______-________ Work #:( )_____-________

Who may we thank for referring you? _____________________

Other family seen by us:________________________________

Employer:_____________________Phone:( )_____-______

Employer Address: ____________________________________

____________________________________________________

ABOUT YOUPERSON RESPONSIBLE FOR ACCOUNT

Name:______________________ Rela

Birthday:___/___/_____ Age:_____ SSN:_____-____-_______

Email:______________________Mobile #:( )_____-______

Home #:( )______-_______ Work #:( )______-_______

Billing Address:_______________________________________

City:____________________ State:__________ ZIP:_________

ACCOUNT INFO

SECONDARY INSURANCE

INSURANCE

MEDICAL HISTORYDo you have a physician? ___YES ___NO

Physician’s Name:_____________________________________

Phone:( )______-________ Last visit date: ___/___/______

Are you currently under a physician’s care? ___YES ___NO

Please explain:________________________________________

___________________________________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:

Name:_______________________ Rela

Phone #:( )_____-_______Alternate #:( )_____-______

Thank you for filling out this form completely. It

We are happy to help!

Provider Name:_______________________________________

Provider Address:______________________________________

City:_________________________________ State:__________

ZIP:______________ Provider’s Phone: ( )_____-________

Group #:_____________________________________________

Insured’s Name:_______________________ Rela

Insured’s Birthday:____________________________________

Insured’s Employer:______________ Phone:( )_____-_____

Insured’s SSN:________________________________________

Insured’s ID#:_________________________________________

Provider Name:_______________________________________

Provider Address:______________________________________

City:_________________________________ State:__________

ZIP:______________ Provider’s Phone: ( )_____-________

Group #:_____________________________________________

Insured’s Name:_______________________ Rela

Insured’s Birthday:____________________________________

Insured’s Employer:______________ Phone:( )_____-_____

Insured’s SSN:________________________________________

Insured’s ID#:_________________________________________

Yes No If yes, when? _______________________

Yes No If yes, when? _______________________

(314) 487-0333 6076 Telegraph Road, St. Louis, MO 63129 oakdc.com rev. 6/14

supplements? Yes No

____________________________________________________

Have you ever taken Phen-Fen (i.e. Redux, Pondimin)

Yes No If yes, when? _______________________

MEDICAL HISTORY

dental treatment? Yes No

Yes No If yes, when? _______________________

OFFICE USE ONLY____________________________________________________ ____________________________________________________

Doctor’s Comments: ____________________________________________________

____________________________________________________

DISCLAIMER

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?(CIRCLE ALL THAT APPLY)

YES NO | AspirinYES NO | CodeineYES NO | PenicillinYES NO | Tetracycline

YES NO | ErythromycinYES NO | Jewelry/MetalsYES NO | Latex

Please list any other drugs/materials that you are allergic to:

____________________________________________________

Sign Here Date

PAYMENT IS DUE IN FULL AT TIME OF TREATMENT

_____________________________________ _____________________________________

ALLERGIES

FOR WOMEN ONLY

Are you pregnant?

Are you trying to get pregnant?

Are you nursing?

Yes No

Yes No Week # ___________

Yes No

Yes No

WE’RE GLAD YOU’RE HERE!

YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |

Abnormal BleedingAcid RefluxAIDS/HIVAlcohol/Drug AbuseAnemia

AsthmaBlood TransfusionsCancer/ChemotherapyCold Sores/Fever Blisters

Congenital Heart DefectCOPDDiabetesDifficulty BreathingEmphysema

Frequent HeadachesGlaucomaHay Fever

Heart MurmurHeart SurgeryHemophilia

High Blood Pressure

Hospitalized (any reason)HypoglycemiaKidney ProblemsLiver DiseaseLow Blood PressureLupusMitral Valve ProlapsePacemakerPsychiatric Problems

SeizuresShinglesSickle Cell DiseaseSinus ProblemsSleep ApneaStrokeThyroid ProblemsTuberculosis (TB)UlcersVeneral Disease

YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |YES NO |

____________________________________________________

____________________________________________________

HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES OR MEDICAL PROBLEMS?

High Cholesterol

(CIRCLE ALL THAT APPLY)

(314) 487-0333 6076 Telegraph Road, St. Louis, MO 63129 oakdc.com rev. 6/14

Our office is HIPAA Compliant

exceeding the standards of

OSHA, the CDC and the ADA.

between meals? YES or NO

Do you snack between meals? YES or NO

Does your mouth feel dry? YES or NO

Is it dry DURING THE DAY or AT NIGHT or BOTH? (circle one)

(laughing gas) YES or NO

PLEASE CHECKMARK ANY OF THE FOLLOWING PROBLEMSTHAT APPLY TO YOU:

Circle one: MANUAL or ELECTRIC toothrush?

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Ear aches or neck pain

Teeth or fillings breaking

Grinding or clenching of the teeth

Bleeding, swollen or irritated gums

______

______

______

______

______

______

______

______

______

______

Dentures______ ______ ______

PLEASE SHARE THE FOLLOWING APPROXIMATE DATES:

Your last cleaning? ___________________________________

Your last oral cancer screening? _________________________

Your last complete X-rays? _____________________________

WHO WAS YOUR PREVIOUS DENTIST?

Name: _____________________________________________

__________________________________________________

City: _________________________ State: ________________

Phone: ( ___)______-_________________________________

Do you smoke or use tobacco products? YES or NO

If yes, how much per day, and for how long? _______________

Have you ever been told you have peridontal disease? YES or NO

Has this been treated in the past? YES or NO

When? ____________________________________________

IF YOU COULD CHANGE YOUR SMILE, YOU WOULD:(select all that apply)

Make your teeth whiter

Make your teeth straighter

Close the gaps/spaces between your teeth

Replace black metal fillings with tooth-colored ones

Repair chipped teeth

Replace missing teeth

Replace old crowns that don’t match

Receive a smile “makeover”

______

______

______

______

______

______

______

______

ON A SCALE OF 1 TO 5, WITH 5 BEING THE HIGHEST,PLEASE RATE THE IMPORTANCE OF THE FOLLOWING

FACTORS TO YOU:

How important to you is your dental health?

1 2 3 4 5

How would you rate your current dental health?

1 2 3 4 5

Where would you like your dental health to rate?

1 2 3 4 5

Bad breath

Missing teeth

Jaw pain

Difficulty sleeping

PLEASE TAKE A MINUTE TO ANSWER THE FOLLOWING QUESTIONS.

What are the most important things to you about your smile anddental health?________________________________________________________

________________________________________________________

________________________________________________________

What is the most important thing to you about your dental visit today?

________________________________________________________

________________________________________________________

Have You Used Tobacco Products In The Past?

When Did You Quit? __________________________________

(314) 487-0333 6076 Telegraph Road, St. Louis, MO 63129 oakdc.com rev. 6/14

SIGNATURE: I, ______________________________, have had full opportunity to read and consider the contents

__________________________________________ ________/________/________

Date: __________/__________/__________

REVOCATION OF CONSENT

Signature: ___________________________________________ Date: ________/________/________

OSHA, the CDC and the ADA.