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Thank you for selecting our dental team! We will always offer you the most up to date dental care available today.
To help us meet your dental needs, please fill out these forms for us.  - Dr. Sanon and Team
Personal Information
Name Wish to be called (Eg nickname)
  Social Sec. # Birth Date (DD/MM/YYYY)
 
Name of the Spouse
Male Female
Single Married Widowed
Address City/State/Zip
Your Employer  Your Occupation
Whom may we thank for referring you to our
office?

Party Responsible For Payment
Name Relation to Patient
 
Address City/State/Zip
Birth Date (DD/MM/YYYY) Social Sec. #
Home Phone
 
Work Phone Extension
IT IS UNDERSTOOD THAT DR. SANON AND STAFF WILL NOT TREAT A PERSON UNDER THE AGE OF 18 WITHOUT THE PARENT OR LEGAL GUARDIAN PRESENT IN THE OFFICE. THIS INCLUDES “CLEANINGS”. AN OLDER SIBLING WILL NOT SUBSTITUTE UNLESS THEY ARE THE LEGAL GUARDIAN.
   
  Signature of Responsible Party
   

Insurance Information
Primary Insurance:
Subscriber Name Relation to Patient
 
Subscriber Address City/State/Zip
Date Of Birth (DD/MM/YYYY)  
 
Social Sec. # Group #
Employer Dental Insurance Company
Insurance Company Address City/State/Zip


Secondary Insurance:

Subscriber Name Relation to Patient
Subscriber Address City/State/Zip
Employer Dental Insurance Company
Date Of Birth (DD/MM/YYYY)
Social Sec. # Group #
Insurance Company Address City/State/Zip

How May We Contact You?
  Home Phone  
   
Work Phone Extension
Cellular Phone Email
Pager Where do you prefer to receive calls?
Home Work
Car Pager
  When is the best time to reach you?
 
Time
   Days
Monday Tuesday
Wednesday Thursday
Authorization And Release
  I authorize Dr. Sanon or his employees to release any information concerning my dental treatment or my child’s to third party payers and/or health practitioners.
 
Signature of Patient or Legal Guardian Date (DD/MM/YYYY)
Medical Concerns
 
Name
Birthday (DD/MM/YYYY) Date (DD/MM/YYYY)
We understand that you are here for us to help you care for your teeth and gums. Medications you are
taking and health problems you may have could make a difference in how we treat your dental problems. Thank you in advance for your cooperation. 		 
MEDICATIONS
What medication are you taking, including "over the conter", i.e. Aspirin, vitamins, etc?
Are you allergic to anything
Penicillin Codeine Latex Other 
HEART PROBLEMS
Your normal blood pressure /
Heart Murmur Stroke Heart Attack Pace Maker Rheumatic Fever Angina  
Heart Valve            
Do you take antibiotics for dental appointments? Yes No
Periodontal Disease and Dental Infections may increase the risk of Stroke and Coronary Disease.
BLEEDING
Do you bleed easily? Aspirin can cause this. Yes No
Are you on Coumadin or other blood thinners? Yes No
Do you have Hepatitis? A B C D Jaundice
Periodontal Disease and Dental Infections may increase the risk of Stroke and Coronary Disease.
DIABETES
Do you have Diabetes? Yes No
Type Type 1 Type 2
Latest HbA1c Score  %
Recent studies have shown a link between Diabetes and Periodontal Disease. It is important to your health that they both be under control. The warning signs of Diabetes are frequent trips to the bathroom, thirsty all the time, and always feeling hungry.  
BREATHING/LUNGS
Sinus problems Seasonal Allergies Bronchitis Asthma Snoring *Ask your Spouse!*
Is it hard to breathe normally through your nose? Yes No
Were your tonsils removed? Yes No
How many times do you wake up at night?    
Do you wake up tired? Yes No
Do you use a CPAP for sleeping? Yes No
PREGNANCY
Are you pregnant? Yes No
Are you taking birth control pills? Yes No
Antibiotics can interfere with birth control pills by causing them not to work. Periodontal infections can increase the risk for low birth weights in newborns. This is very dangerous!  
CANCER
Do you have cancer? Yes No
Have you ever had cancer? Yes No
When?  
What Kind?  
How are you being or were you treated? Surgery Chemotherapy Radiation
GENERAL QUESTIONS
Do you smoke? Yes No
How many packs a day?  
Are you nervous?
*Not just because you are in a dental office*		 Yes No
Do you have a Mental Health Disorder? Yes No
What is it?  
Do you need help sleeping? Yes No
What do you do?  
Do you have to go to the bathroom often? Yes No
Do you get dizzy often or if you stand up too fast? Yes No
Do you feel bad if you skip lunch? Yes No
NERVES/MUSCLES/BONES
Do you have back problems? Yes No
Can you lie in a dental chair comfortably? Yes No
Do you have Neuromuscular Disorder? Yes No
What is it?  
IMMUNE SYSTEM
Lupus Organ Transplant HIV AIDS ARC
PHYSICIANS/PHYSICAL THERAPIST/CHIROPRACTORS
Name Phone#
Treatment  
 
 
Name Phone#
Treatment  
 
PERSON TO CONTACT IN CASE OF AN EMERGENCY
Name Phone#
Relation Alt Phone#
ANYTHING ELSE YOU FEEL WE NEED TO KNOW ABOUT THE SYSTEMS OF YOUR BODY
Dental Concern
 
What can we do to make you feel more at home?
  Would you like to be reminded of your appointments?
  Would you like fresh coffee when you arrive?
  Would you like a personal Walkman or a CD Player to listen to?
  Will you need blankets to help with the temperature?
  Will you need a pillow to support your neck?
  Would you like sunglasses to wear during your appointment?
Anything we have not thought of?
What did you not like about your past dental appointments?
  Was the treatment uncomfortable?
  Was the staff unfriendly?
  Were the fees not explained before your appointments?
Anything we have not thought of?
What are your feelings about your:
  Front Teeth
 
Are you happy with their color? Yes No
Are you happy with their length? Yes No
Are they crowded or crooked? Yes No
Are braces an option? Yes No
Are you happy with their overall appearance? Yes No
Anything about them you would change?
  Back Teeth
 
Are they sensitive to hot or cold foods? Yes No
Do they trap food when you eat? Yes No
Anything about them you would change?
  Gums
 
Are your gums red and swollen? Yes No
Do your gums bleed when you brush your teeth? Yes No
Have you had non surgical periodontal therapy? Yes No
 
When?
 
Have you had surgical periodontal therapy? Yes No
 
When?
Anything else that you would like to share regarding your teeth and gums?
Consent:

The undersigned hereby authorize the Doctor to take x-rays, study models, photographs, or any diagnostic aids deemed appropriate to make a thorough diagnosis of the patient’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy, and further authorize any consent that the Doctor chose and employ such assistance as he/she deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for my self or my dependent is mine, due and payable at the time services are rendered unless financial arrangements have been made. In the event of default I (We) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to affect collection of this note. 		 
Patient Date (DD/MM/YYYY)
Witness Parent Or Responsible Party
 
Relationship To Patient  
 
 
 
 
Manish Sanon, D.D.S., Smile Center
2067 Fairport-Nine Mile Point Road Suite 150
Penfield, NY 14526

Tel: (585) 377-3130
 
   
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