Southern Vermont Endodontics, PC
Root Canal Specialists

71 Allen Street, Suite 204
Rutland, Vermont 05701
Phone Number: 802-773-7767
Fax Number: 802-775-7667


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Patient Information
Patient's Name:
Date of Birth:
Social Security Number:
Name of Spouse
If Child, Parent Name
Mailing Address:
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Phone Number:
Work Phone Number:
Cell Phone Number:
Patient 's Employer:
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Insurance Information
Purpose of this Appointment:
Name of Insurance Card Holder:
Relation to Patient:
Social Security Number:
Date of Birth:
Name of Employer:
Date Employed:
Phone:
Mailing Address:
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Name of Insurance Company:
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Insurance Co. Address
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Whom may we thank for referring you?:
Comments:

Additional Insurance Information
Do You Have Any Additional Dental Insurance
Name of Insurance Card Holder:
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Date Employed:
Address
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Health History
Physician's Name:
Physician's Phone Number:
Date of Last Visit:
Are You Presently Under a doctor's Care?
 Yes No
If Yes, explain why:
Are You Currently Taking Any Medications?
 Yes No
If Yes please list them:
Do you have to be premedicated with antibiotics for dental treatment?

Allergies:

 Yes No
Local Anesthetic (novocaine, lidocaine, xylocaine)
Latex
Erythromycin
Penicillin (or other antibiotics)
Other:
Are you Pregnant?
Are you Nursing?

Please check any of the following which you have or have had:

Yes No
Anemia
Asthma
Bleeding Difficulties
Diabetes
Emphysema
Glaucoma
Heart Murmur
Hepatitis
High Blood Pressure
Low Blood Pressure
Arrhythmia
Heart Attack or Heart Failure
Kidney Disease
Mitral Valve Prolapse
Joint Replacement
Stroke
Rheumatic Fever or Scarlet Fever
Other:

Is there anything we should know about your past dental experiences?
Do you presently have a toothache?

Have you had Root Canal Therapy in the past?