Patient Information Update Home NEW PATIENT FORM Patient Information Update Patient InformationName* First Last DOB* Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneWork PhonePreferred method of contact* Email Text Call home Call cell Call work Dental InsuranceI have Dental Insurance* Yes No Carriers* Primary Secondary Primary CarrierPolicy Holder* First Last Birth Date* ID / Social Security #* Insurance Company* Phone*Group Policy #* Employer* Secondary CarrierPolicy Holder* First Last Birth Date* Social Security #* Insurance Company* Phone*Group Policy #* Employer* Medical HistoryDo you have or have you had any of the following? (kept strictly confidential)Heart Problems* Yes No Heart Murmur* Yes No Mitro Valve Prolapse* Yes No High Blood Pressure* Yes No Heart Attack* Yes No Low Blood Pressure* Yes No Rheumatic Fever* Yes No Stroke* Yes No Fainting or Convulsions* Yes No Tuberculosis* Yes No Asthma* Yes No Allergies* Yes No Allergies to Medications* Yes No Diabetes* Yes No Abnormal Bleeding* Yes No Hepatitis* Yes No Headaches* Yes No Malignancies* Yes No Psychiatric Care* Yes No Herpes* Yes No Venereal Disease* Yes No HIV Positive* Yes No AIDS Related Complex* Yes No Auto Immune Deficiency* Yes No Any Prosthetic Devices* Yes No Implants* Yes No Artificial Knee, Hip, Joint, Pins, Plates* Yes No Women: Are you Pregnant? Yes No Chemical Dependency* Yes No Drug Addiction* Yes No Past or Present Eating Disorders* Yes No Heart Attack Year* List Allergies to Medications* Hepatitis Type* Pregnancy Month* Have you ever been told to pre-medicate with antibiotics before dental treatment?* List all medications you are taking (prescription, over the counter and supplements):* Date* MM slash DD slash YYYY Consent Cancellation PolicyDr. Peggy Myers is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen. We understand that situations arise in which you must cancel your reserved appointment. It is therefore requested that if you must cancel your reserved appointment you provide at least 48 hour notice. To cancel a Monday appointment, please call our office by 2:00 p.m. on Wednesday. If prior notification is not given, you will be charged $100 for the cancelled or missed appointment. Consent I agree.I have read all the information on this sheet and completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or other information.Signature* By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.