Hugh J Howard DDS
Click here to print the Patient Paperwork
144 South State St. La Verkin, UT 84745
(435) 635-4244 www.hughhowardds.com
First Name (required)
(Check all that applies)
Sex: Male Female Minor Single Married
Driver's License Number
Social Security Number
In case of emergency, who should be notified?
Relationship to Patient
Payment Method Cash Credit Card/Debit Card Care Credit Check
I hereby authorize assignment of my insurance rights and benefits directly to Hugh J. Howard D.D.S. for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance.
Check here if address is the same as above
(If patient is a minor under 18, please complete the next section for the child's parent/guardian)
Relationship to Patient
Home Address (if different from above)
Payment Method Cash Credit Card /Debit Card Care Credit Check
I hereby authorize assignment of my insurance rights and benefits directly to Hugh J. Howard D.D.S. for services rendered.
I fully understand that I am solely responsible for any balance not paid by my insurance company.
Dental Insurance Yes No
Insurance Phone Number
Approximate date of last dental appointment
Reason for first visit with us
Please add anything that you feel is important for the doctor to know
Please fill in the yes or no circle to the following questions:
Are you having PAIN, SWELLING, or SORE SPOTS at this time? Yes No
Do your GUMS BLEED? Yes No
Have you had PERIODONTAL TREATMENTS? Yes No
Do you have REMOVABLE dentures or partials? Yes No
Is this your FIRST VISIT to any dentist? Yes No
Have you had any COMPLICATIONS with dental treatment? Yes No
Have you been treated for TMJ (Temporomandibular Joint problems)? Yes No
Do you have a FEAR of Dentistry? Yes No
If yes, why?
Name of Your Primary Care Physician
Date of last physical
Are you taking any MEDICATIONS now (PRESCRIPTION AND/OR OVER-THE-COUNTER)? Yes No
If yes, please list
Women: Are you Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?
Are you allergic to any of the following? ACRYLIC ASPIRIN CODEINE LOCAL ANESTHETIC LATEX METALS PENICILLIN SULFA OTHER
Are you currently taking Coumadin, Warfarin or other BLOOD THINNERS? Yes No
Do you have or have had at any time, any of the following?
Have you ever had any serious illness not listed above? Yes No
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform Hugh J. Howard D.D.S. of any changes in medical status.
I CERTIFY THAT THE ANSWERS TO THE HEALTH QUESTIONS ARE ACCURATE AND CORRECT TO THE BEST OF MY KNOWLEDGE