JASMINE SUNG DDS

6918 Corporate Dr. Ste. A-11 Houston, TX 77036

(713) 777-1221




PATIENT INFORMATION

We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we’ll be glad to help you.

PERSONAL:

First Name:
Last Name:
MI:
Date:
Birth Date:
SS# :
Gender:
Married:
Cell Phone:
Home Phone:
Work Phone:
Address:
Address 2:
City:
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Zip Code:
E-Mail Address:
Preferred contact method:
Spouse or Parent/Guardians Name :
How did you hear about us?

(If someone referred you here, please write down their name so we can thank them.)

INSURANCE POLICY 1

Your relationship to subscriber:
Subscriber Name:
Subscriber DOB:
Subscriber ID #:
Insurance Company:
Phone:
Employer:
Group Name:
Group #:

INSURANCE POLICY 2

Your relationship to subscriber:
Subscriber Name:
Subscriber DOB:
Subscriber ID #:
Insurance Company:
Phone:
Employer:
Group Name:
Group #:

PLEASE PRESENT INSURANCE CARD AND DRIVERS LICENSE TO RECEPTIONIST.



MEDICAL HISTORY:

Physician:
Office Phone:

List all the medications or drugs you are now taking:

Are you allergic to any of the following?

Anesthetic:
Aspirin:
Codeine:
Ibuprofen:
Iodine:
Latex:
Penicillin:
Sulfa:

Do you have any of the following Medical Conditions?

Asthma?
Bleeding Problems
Cancer
Diabetes?
Heart Murmur?
Heart Trouble
High Blood Pressure
Joint Replacement
Tobacco Use
Kidney Disease
Liver Disease
Pregnancy
Psychiatric Treatment
Sinus Trouble
Stroke
Ulcers
Rheumatic Fever

Additional Information:

Any other medical condition details?

Any dental conditions we should be aware of?

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Date:

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