Dr.Karen Kucharski, DMD

Name: _________________________________________________________________ 

Preferred Name:

__________________________________________________________________

Male  Female

Address: _________________________________________  City_________________ State ______ ZIP_____________

SSN: ______________________________________ DOB: _________

Home Phone: ________________________ Work Phone: __________________

Cell Phone:___________________________________

E-mail Address: ________________________________________

Employer:____________________________________

Occupation: __________________________________________

Marital Status:  Single  Married  Divorced  Widowed  Separated  Domestic Partner

How did you hear about our office?__________________________________________________________________

Do you prefer to be contacted for appointment confirmation via e-mail or phone? (Please circle preference)

Insurance – Primary

Subscriber Name: _________________________________________________

Relationship to Patient: _________________ Subscriber DOB: _____________

Subscriber SSN/ID: ________________________________________________

Subscriber Employer: _______________________________________________

Insurance Company Name:____________________________________________________________

Insurance Company Address:___________________________________________________________

Insurance Company Phone: __________________GroupNumber______________

Insurance – Secondary

Subscriber Name: _________________________________________________

Relationship to Patient: ______________________ Subscriber DOB: _________

Subscriber SSN/ID: ___________________Subscriber Employer_____________

Insurance Company Name:____________________________________________________________

Insurance Company Address:____________________________________________________________

Insurance Company Phone: ____________________Group Number: ____________

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Today’s Dental all insurance

benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges

whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of

benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature: _________________________________________________________________

Relationship: _________________________________________ Date: ______

CONSENT: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

Patient/Guardian Signature:___________________________________________________________

Tell Us About Yourself

Do you have a personal physician? ❑ Yes ❑ No

Physician’s Name:____________________________________________________________

Physician’s Phone: __________________________________________________________________

Date of last visit: ___________________________________________________________________

Your current physical health is: ❑ Good ❑ Fair ❑ Poor

Are you currently under the care of a physician? ❑ Yes ❑ No

Please explain: ___________________________________________________________________

Do you use tobacco in anyform? ❑ Yes ❑ No

Have you had any metal rods, pins or implants placed? ❑ Yes ❑ No

Are you taking any medications? ❑ Yes ❑ No

Please list each one: ___________________________________________________________________

Have you ever had any surgical procedures? ❑ Yes ❑ No

Please list each one: ___________________________________________________________________

Nearest relative not living with you:

Name: __________________________________Relationship: ____________

Address: _____________________________________ Phone: _____________

Medical History

Yes No Conditions

❑ ❑ Abnormal Bleeding

❑ ❑ Alcohol Abuse

❑ ❑ Allergies

❑ ❑ Anemia

❑ ❑ Angina Pectoris

❑ ❑ Arthritis

❑ ❑ Artificial Heart Valve

❑ ❑ Asthma

❑ ❑ Blood Transfusion

❑ ❑ Cancer

❑ ❑ Chemotherapy

❑ ❑ Colitis

❑ ❑ Congenital Heart Defect

❑ ❑ Diabetes

❑ ❑ Difficulty Breathing

❑ ❑ Drug Abuse

❑ ❑ Emphysema

❑ ❑ Epilepsy

❑ ❑ Facial Surgery

❑ ❑ Fainting Spells

❑ ❑ Fever Blisters

❑ ❑ Frequent Headaches

Yes No Conditions

❑ ❑ Glaucoma

❑ ❑ HIV+ AIDS

❑ ❑ Heart Attack

❑ ❑ Heart Murmur

❑ ❑ Heart Surgery

❑ ❑ Hemophilia

❑ ❑ Hepatitis A

❑ ❑ Hepatitis B

❑ ❑ Hepatitis C

❑ ❑ High Blood Pressure

❑ ❑ Joint Replacement

❑ ❑ Kidney Problems

❑ ❑ Liver Disease

❑ ❑ Low Blood Pressure

❑ ❑ Mitral Valve Prolapse

❑ ❑ Pace Maker

❑ ❑ Psychiatric Problems

❑ ❑ Radiation Therapy

❑ ❑ Rheumatic Fever

❑ ❑ Seizures

❑ ❑ Sexually Transmitted Disease

❑ ❑ Shingles

Yes No Conditions

❑ ❑ Sickle Cell Disease

❑ ❑ Sinus Problems

❑ ❑ Stroke

❑ ❑ Thyroid Problems

❑ ❑ Tuberculosis

❑ ❑ Ulcers

Yes No Allergies

❑ ❑ Aspirin

❑ ❑ Codeine

❑ ❑ Dental Anesthetics

❑ ❑ Erythromycin

❑ ❑ Jewelry

❑ ❑ Latex

❑ ❑ Metals

❑ ❑ Penicillin

❑ ❑ Tetracycline

Yes No If Female, Please Answer

❑ ❑ Are you taking Birth

Control Pills?

❑ ❑ Are you pregnant?

If so, # of Weeks _______

❑ ❑ Are you nursing?

Your current dental health is: ❑ Good ❑ Fair ❑ Poor

Do you require antibiotics before dental treatment? ❑ Yes ❑ No

Are you currently in pain? ❑ Yes ❑ No

Have you ever had gum treatment? ❑ Yes ❑ No

Do you now or have you had any pain/discomfort in your jaw joint? (TMJ) ❑ Yes ❑ No

Do you like your smile? ❑ Yes ❑ No

Is there anything you would like to change about your smile? ❑ Yes ❑ No

Are you happy with the color of your teeth? ❑ Yes ❑ No

Do your gums bleed? ❑ Yes ❑ No

How many times a do you: floss/week?____________ brush/day?____________

Are your teeth sensitive to head, cold or anything else? ❑ Yes ❑ No

Have you lost any teeth? ❑ Yes ❑ No

Have you ever had a serious/difficult problem with any previous dental work? ❑ Yes ❑ No

Have you ever had any unfavorable dental experiences? ❑ Yes ❑ No

When was your last dental cleaning/visit? _________________________________________________________________

Why did you leave your previous dentist? _________________________________________________________________

How can we accommodate you better during your dental visit?________________________________________________________________

Nearest relative not living with you:

Name: ___________________________________ Relationship: ____________

Address: ______________________________________ Phone:______________

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information

will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature: ____________________________________________________ Date: ________________________________