Patient Information

* First Name:
* Last Name:
*Social Security Number:
Preferred Name/Nick Name:
* Street Address:
* City:
* State:
* Zip Code:
How Long at this Address:
* Birthdate:
Marital Status:
* Email Address:
* Home Phone:
Work Phone:
Cell Phone:
Patient Employed by:
Whom may we thank for referring you?:
In case of emergency, who should be notified: (Someone not living in your household)
Emergency Relation:
Emergency Phone:

Dental History

Reason for today's visit:
Any other dental questions or concerns:
Would you like whiter teeth?:
Date of last dental visit:
Date of last dental x-rays:


List Medications you are currently taking:
FOSAMAX (Bisphosphonate)


(sleeping pills)
Local Anesthetic

Health History

Physician's Name:
Date of last visit:
(Women) Are you pregnant?
Taking oral contraceptives?
Have you had surgery in the last 6 months?
Do you need to be premedicated for dental work?

Check if you have had any of the following:
Stroke Sinus Trouble HIV
Heart Disease/Surgery Asthma Hives or Rash
Heart Murmur Bloody Sputum Drug Addiction/Alchoholism
Irregular Heart Beat Emphysema Cold Sores
Angina/Chest Pain Turberculosis (TB) Fever Blisters
Heart Attack/Failure Cancer Herpes
Congenital Heart Disorder X-Ray Treatments (Radiation) Convulsions
Mitral Valve Prolapse Chemotherapy Epilepsy or Seizure
Scarlet Fever Ulcers Fainting or Dizziness
Rhuematic Fever Recent Weight Loss Glaucoma
Atrificial Heart Valve Diabetes Tumors or Growths
Heart Pacemaker Liver Disease Nervousness
Pulmonary Shunt Hepatitis Psychiatric Care
High Blood Pressure Kidney Problems Ever taken fen-phen?
Low Blood Pressure Renal Dialysis
Bacterial Endocarditis Thryoid Disease    
Luekemia Arthritis/Gout    
Other Blood Disorders Rhuematism    
Lung Disease Cortizone Medicine    
Frequent Cough Artificial Joint Other

Policy and Consent Documents

Please be sure to print and fill out these forms prior to your first visit!
I have read and agree to the policies stated in the above documents  

Authorization and Release

I have read and asnwered the above questions to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.

* Electronic Signature of patient or parent if minor

  * = required
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Visit Westerville Dental Health Today! Westerville Dental Health
Stephen R. Malik, DDS
180 Commerce Park Drive
Suite B
Westerville, OH 43082

Telephone: 614.882.6741
Facsimile: 614.882.6718
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