Chapel Hill Periodontics & Implants
Timothy W. Godsey, D.D.S., M.S., P.A.
Practice Limited to Periodontics
150 Providence Road, Suite 200
Chapel Hill, NC27514
PATIENT INFORMATION
Patient Name: ______Date:______
Last First MI
How do you prefer to be addressed by the doctor and staff?______
Please circle one:Mr.Mrs.Ms.Miss.Dr.Rev.Other:______
Address: ______Home phone:______
______Work phone: ______Ext.______
______Cell phone: ______
Date of Birth______
SSN(if insured)______Male ______Female ______
Email ______
Marital Status: Married ______Single ______Divorced ______Widowed ______
In case of emergency please call ______Phone # ______
Whom can we thank for referring you to our practice? ______
EMPLOYMENT INFORMATION
Occupation/Former Occupation:______
Employer Name/Former Employer Name: (please no abbreviations)______
Employer Address: ______
City: ______State: ______Zip Code: ______
SPOUSE OR PARENT EMPLOYMENT INFORMATION
Spouse or Parent’s Name: ______
Occupation: ______
Employer Name: (please no abbreviations) ______
Employer Address: ______
City: ______State: ______Zip Code: ______
If spouse or parent carries the insurance, please provide the following information:
Social Security #: ______Date of Birth ______
Please note that the adult accompanying a minor (under the age of 18) is financially responsible for that patient, no exceptions.
I have completed this form fully and completely and certify that I am the patient or duly authorized general agent of the patient authorized to furnish the information requested.
I understand that payment for professional services is the sole responsibility of the patient and is due as services are rendered. We do not render services on the basis that insurance companies will pay our fees, but we will be happy to assist you in filing claims for insurance reimbursement.
______
Date Signature of Patient or Parent Relationship to Patient
Yes No Conditions Yes No Conditions Yes NoConditions
Heart MurmurEpilepsyThyroid Problems
Rheumatic FeverFainting SpellsTuberculosis
Mitral Valve ProlapseFever BlistersUlcers
Congenital Heart DefectFrequent HeadachesVenereal Disease
Artificial Heart ValveGlaucomaTaken Fosamax or other
Heart AttackHIV AIDS medications for
Alcohol AbuseHeart Surgery Osteoporosis
AllergiesHemophiliaDo you premedicate with
AnemiaHepatitis A antibiotics prior to all
Angina PectorisHepatitis B dental appointments
ArthritisHigh Blood Pressure
AsthmaHip Replacement Yes No Allergies
Blood TransfusionKnee Replacement Aspirin
Abnormal BleedingKidney Problems Codeine
Bruise EasilyLiver Disease Dental Anesthetics
Coumadin TherapyLow Blood Pressure Erythromycin
Cancer ChemotherapyPace Maker Latex
ColitisPsychiatric Problems Metals
DiabetesSeizures Penicillin
Difficulty BreathingSickle Cell Disease Tetracycline
Drug AbuseStroke Other______
EmphysemaTaken Fen Phen
Do you suffer from Sleep Apnea or do you use a C-PAP machine? Yes ______No ______
Have you traveled to an Ebola-affected area in the past 21 days? Yes______No______
If female, please answer the following:Please answer the following:
Y N
Are you taking Birth Control Pills?Y N
Are you Pregnant?If Yes, # of weeksDo you smoke or use tobacco?
Are you nursing?If yes how many packs a day? ______
For how long? ______
Medications:Medical Physician:______
Phone #______
Address ______
______
______
YN
Is there any disease, condition, or problem that you think this office should know about that is not covered above? If yes, describe below…….
Signature: ______Date: ______
(If under 18, Parent or Guardian Signature required)