PLEASE READ THIS BEFORE BEGINNING THIS FORM:
It is best to be organized for this form - Collect the Following:
1. Dental Insurance Information and a Copy of your Insurance Card (if you have one).
2. Prescriptions - If you have a list already prepared you can attach it to this form. If you don't have a formal list you will be asked for
a) Name of each Medication
b) Dose & Frequency
c) Purpose (Example: High Blood Pressure)
d) Prescribing Physician (or self)
3. Supplements, Vitamins, & Over the Counter Medications - If you have a list already prepared you can attach it to this form. If you don't have a formal list you will be asked for
a) Name of each Item
b) Dose & Frequency
c) Purpose
d) Prescribing Physician (or self)
3. Physicians - Contact Information including the name, specialty, phone, city, and other information if you have it.
4. Photo ID (It is not required but helpful!)