JASMINE SUNG DDS

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

(713) 777-1221




PATIENT INFORMATION 病人資料表

請您盡力完成填寫此表格。如果您有任何疑問，我們將很樂意為您提供幫助。

PERSONAL INFORMATION 個人資料:

Name (名):
Last Name (姓):
Middle Name(中名) :
Date (今天日期):
Birthdate (出生日):
Social Security # (社會保險号碼):
Gender (性别):
Married (婚姻狀況):
Mobile (手機):
Home Phone (家庭電話):
Work Phone (工作電話):
Address (地址):
Address 2 (地址):
City (城市):
State (州):
Zip (郵區編碼):
Email (電子郵件):
Preferred Contact Method (首選聯繫方式):
Spouse or Parent/Guardians Name (配偶或父母監護人姓名):
How did you hear about us? (推薦人姓名)

INSURANCE POLICY 1 (牙科保險1)

Your relationship to subscriber (您与投保人的關係):
Subscriber Name (投保人姓名):
Subscriber DOB (投保人出生日):
Subscriber ID (投保人编號):
Insurance Company (保險公司):
Phone (保險電話):
Employer (雇主):
Group Name (組名):
Group # (組號碼):

INSURANCE POLICY 2 (牙科保險2)

Your relationship to subscriber (您与投保人的關係):
Subscriber Name (投保人姓名):
Subscriber DOB (投保人出生日):
Subscriber ID (投保人編號):
Insurance Company (保險公司):
Phone (保險電話):
Employer (雇主名):
Group Name (組名):
Group # (組號碼):

PLEASE PRESENT INSURANCE CARD AND DRIVER LICENSE TO RECEPTIONIST (請出示牙科保險卡和駕駛執照).



MEDICAL HISTORY 病歷表:

Emergency Contact (緊急聯繫人):
Phone (電話):
Physician (醫生姓名):
Phone (醫生電話):

List all of the medications or drugs you are taking now (請列出您所有正在服用的藥物):

Allergies 过敏症:

Are you allergic to any of the following? (您對下列任何一種過敏嗎)?
Anesthetic 麻
Aspirin 阿司匹林:
Codeine 可待因:
Ibuprofen 布洛芬:
Iodine 碘:
Latex 膠乳:
Penicillin 青黴素:
Sulfa 磺胺藥:
Anything else (還有別的嗎)？

Medical Conditions 医疗条件:

Do you have any of the following medical conditions (您是否患有以下任何的疾病)?
Asthma 哮喘
Bleeding Problems 出血問題
Cancer 癌症
Diabetes 糖尿病
Heart Murmur 心雜音
Heart Trouble 心臟疾病
High Blood Pressure 高血壓
Tobacco Use 煙草使用
Kidney Disease 腎臟疾病
Liver Disease 肝病/肝炎
Pregnancy 懷孕
Psychiatric Treatment 精神科治療
Sinus Trouble 鼻竇炎
Stroke 中風
Ulcers/Stomach Trouble 潰瘍/ 胃病
Rheumatic Fever 風濕熱

Additional Information (附加信息):

Any other medical conditions and details (任何其他醫療狀況和細節)?

Any dental conditions we should be aware of (我們應該注意的任何牙齒狀況)?

Signature (病人簽名):

Use your mouse cursor or the tip of your finger to sign below

Date (今天日期):