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*YesNoCarriers* 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*YesNoHeart Murmur*YesNoMitro Valve Prolapse*YesNoHigh Blood Pressure*YesNoHeart Attack*YesNoLow Blood Pressure*YesNoRheumatic Fever*YesNoStroke*YesNoFainting or Convulsions*YesNoTuberculosis*YesNoAsthma*YesNoAllergies*YesNoAllergies to Medications*YesNoDiabetes*YesNoAbnormal Bleeding*YesNoHepatitis*YesNoHeadaches*YesNoMalignancies*YesNoPsychiatric Care*YesNoHerpes*YesNoVenereal Disease*YesNoHIV Positive*YesNoAIDS Related Complex*YesNoAuto Immune Deficiency*YesNoAny Prosthetic Devices*YesNoImplants*YesNoArtificial Knee, Hip, Joint, Pins, Plates*YesNoWomen: Are you Pregnant?YesNoChemical Dependency*YesNoDrug Addiction*YesNoPast or Present Eating Disorders*YesNoHeart 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* Date Format: 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.