BOCA MICRO-SURGICAL ENDODONTICS
Robert S. Mullaney, D.D.S. Diplomate American Board of Endodontics
John Thomas Hancock, D.D.S. Diplomate American Board of Endodontics

Name
Spouse's Name
Address
Street
City
State
Zip
Phone
Cell

Marital Status Married Single Divorced Widow

Occupation
SSN
Date of Birth
Business Name
Business Phone
Person Financially Responsible
Is treatment partially covered by dental insurance? Yes No

Dental History

Referring Dentist
City of Referring Dentist
Reason for Referral
Are you having discomfort presently? Yes No
Have you experienced previously Yes No
Is the tooth sensitive to heat? Yes No
Was the tooth previously sensitive to heat? Yes No
Is the tooth sensitive to cold? Yes No
Was the tooth sensitive to cold previously Yes No
Do you experience discomfort when biting? Yes No
Are you experiencing swelling? Yes No
Were you experiencing swelling previously? Yes No
For how long have you experienced pain?
Can you localize pain to one tooth?

Medical History

Your physician's name:
City
Date of your last medical examination: (MM/DD/YY)
Are you currently taking medication? Yes No
If so, please list:
Are you allergic to, or have been told not to take any drugs ie:
Penicillin, Aspirin, Codeine, Novocaine or others? Yes No
If so, please list:
Females -- are you pregnant? Yes No

Which of the following apply to you?

Diabetes Anemia or Blood Disorder Cancer
Allergies Heart Problem Stroke
Sinus Problems Rheumatic Fever Sexually Transmitted Disease
Hepatitis, Jaundice or Liver Disease Mitral Valve Prolapse HIV Infection
Tuberculosis Congestive Heart Failure AIDS
Kidney Problems Heart Surgery Epilepsy/Seizures/Fainting Spells
Psychiatric Problems Pacemaker Drug Alcohol Abuse
Hemophilia / Abnormal Bleeding Heart Valve Replacement Major Operation
Difficulty Breathing Implant Prosthesis Hip/Knee Hormonal Imbalances
Arthritis High/Low Blood Pressure Stomach Ulcers
Hypertension

Is there anything else you think important for us to know?

Please Read

Upon treatment completion, your tooth may require a final restoration -- possibly a crown -- which your referring dentist will perform.

In regards to our Business Policy, most patients find it convenient to make payments as treatment progresses. It is expected, however, that the fee is due in full upon your last visit.

If you have a dental insurance claim, our office will gladly complete any insurance forms. However, fees are the direct obligation of the patient.

Please familiarize yourself with some basic information on endodontic therapy by clicking here, and feel free to ask the staff any questions which may arise during your treatment period.


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