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Nashville Dentists
Visit Our Office:


Drs. Elam, Vaughan
and Fleming
2125 Blakemore
Nashville Tn, 37212
Ph: 615 383 3690


Office Hours:
7:30am to 5pm
Monday - Thursday
Fridays 8am to 12


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Dentistry Procedures




Drs. Elam, Vaughan
and Fleming
2125 Blakemore
Nashville Tn, 37212
Ph: 615 383 3690



Office Hours:
7:30am to 5pm
Monday - Thursday
Fridays 8am to 12
Medical History Form

Patient Information
Date
   Pt. #
Home Phone
   Full Name (last, first & middle initial)
Social Sec #
  Address
State
   Zip
Cell Phone
   E-mail Address
Gender: Male Female
  Age
Birthdate
    
Marital Status:
Minor Single Married

Divorced Widowed Separated

Patient Employed By
  Occupation
Business Address
   Business Address
Who may we thank for referring you?
In the event of an emergency
who should we contact?
  
Phone



Primary Insurance:
Person Responsible for Account
Relationship to Patient
Birthdate
Social Security number
Address (if different from patient's)
Phone
Employed By
Occupation
Business Address
Business Phone
Insurance Company
Contract #
Group #
Subscriber #
Other Dependents Covered by this Plan
Is patient covered by additional insurance? Yes No
Additional insurance:
Subscriber Name
Relationship to Patient
Birthdate
Address (if different from patient's)
Phone
Employed By
Occupation
Business Address
Business Phone
Insurance Company
Social Security number
Contract #
Group #
Subscriber. #
Other Dependents Covered by this Plan

Dental History:  
Reason for Today's Visit
 Date of Last Dental Care
Former Dentist
Date of last Dental X-rays
Address
 

Check the boxes if you have had problems with any of the following:
Bad Breath Grinding Teeth
Bleeding Gums Loose Teeth or Broken Fillings
Clicking or Popping Jaw Periodontal Treatment
Food Collection Between Teeth Sores or Growths in the Mouth
Sensitivity to Cold Sensitivity to Hot
Sensitivity to Sweets Sensitivity when Biting
How often do you floss?
 How often do you Brush?


Medical History:  
Physicians Name
Date of Last Visit

Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? these include combinations of Ionimin, Adipex,Fastin (brand names of phentramine), Pondimin (fenfluramine) and Redux (dexfenfluramine) Yes No
Have you had any illnesses or operations?
Yes No 		If yes please describe
Have you ever had a blood transfusion?
Yes No 		If yes, give approximate dates
Are you pregnant?
Yes No 		Are you Nursing?
Yes No
Taking birth control pills?
Yes No 		 

Check the boxes if you have or had any of the following:
Anemia Arthritis, Rheumatism Artificial Heart Valves
Artificial Joints Asthma Back Problems
Blood Disease Cancer Chemical Dependency
Chemotherapy Circulatory Problems Cortisone Treatments
Cough, Persistent Cough up Blood Diabetes
Epilepsy Fainting Glaucoma
Headaches Heart Murmur Heart Problems
Hemophilia Hepatitis High Blood Pressure
HIV/AIDS Jaw Pain Kidney Disease
Liver Disease Mitrial Valve Prolapse Pacemaker
Radiation Treatment Respiratory Disease Rheumatic Fever
Scarlet Fever Shortness of Breath Skin Rash
Stroke Swelling in Ankles/Feet Thyroid Problems
Tobacco Habit Tonsillitis Tuberculosis
Ulcer Venereal Disease  

Medications
List any medications you are currently taking:

Allergies
List any allergies:

Dental History:
 By Clicking Submit; I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure payment of benefits.
I understand that I am financially responsible for all charges whether or not paid by insurance.

Name

Date


Payment is due in full at time of treatment
unless prior arrangements have been approved.
  

To learn more about our practice, please contact us today!