Dr. Eric Baugher | Dr. Jennifer Claiborne | Dr. Bruce Bentley7802 Timberlake Road, Lynchburg, VA 24502
434.385.GRIN (4746) | www.bracesbycvo.com
Patient’s Last Name: ___________________ First Name: ___________________ Common Name:___________________
Address: ______________________________________________________________________________________
Home #: ____________________________ Cell #: _______________________ Email: ___________________________
Birth Date: ________________ Age: ______ Sex: F / M Grade: _______________ School: __________________________
Hobbies: _________________________________________________________ Referred by: ______________________
Siblings & Age: __________________________________________________________________________________
PARENT OR GUARDIAN INFORMATION (for patients under 18)
Parent/Guardian: _______________________ Home #: ______________________ Cell #: ___________________________
Address (if different): ______________________________________________________________________________
Employer: ________________________________________________________ Email: ___________________________
Relationship to Patient: ______________________________________________ Birth Date: ________________________
Parent/Guardian: _______________________ Home #: ______________________ Cell #: ___________________________
Address (if different): ______________________________________________________________________________
Employer: ________________________________________________________ Email: ___________________________
Relationship to Patient: ______________________________________________ Birth Date: ________________________
Has patient ever seen another orthodontist? Y / N Name: _____________
__________ Is this a second opinion? Y / N
Patient’s Dentist: ___________________________________________________ Date last seen: ______
Patient’s Physician: ________________________________________________________________________________
Name of other family members seen in our office: __________________________________________________________
What concerns do you have about your/or your child’s teeth? __________________________________________________
Who suggested that you/or your child might need orthodontic treatment? _________________________________________
Person financially responsible for this account: _____________________________ Relationship to patient: _______________
Address (if different): ______________________________________________________________________________
Home #: ____________________________ Cell #: _______________________ Email: ___________________________
SS #: _______________________________ Employer: _______________________
Primary Insured’s Name: ____________________________________________ SS #: ____________________________
Birth Date: ___________________________ Insurance Company: ______________________________________________
Employer: ____________________________ Group #: _____________________ ID #: ___________________________
Primary Insured’s Name: ____________________________________________ SS #: ____________________________
Birth Date: ___________________________ Insurance Company: ______________________________________________
Employer: ____________________________ Group #: _____________________ ID #: ___________________________
Drug or other allergies? List: ______________________________________________________________________________________
Allergies to Latex / Rubber Gloves / Metals / Plastics? (circle which if answer is yes)
Has the patient ever taken intravenous bisphosphonates such as Zometa, Aredia or Didronel?
Has the patient ever taken oral bisphosphonates such as Fosomax, Actonel, Boniva, Skelid or Didronel?
Has the patient ever had problems associated with any previous dental work?
Has the patient ever experienced pain, clicking or popping in the jaw joint?
Has the patient’s jaw joint ever locked or felt like it was sticking?
Has the patient ever had an injury to the mouth/teeth/chin?
History of speech problems or speech therapy?
Does the patient play a musical instrument?
Has the patient ever had any of the following medical issues?
I authorize the release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. I certify that the above information is accurate and understand that an appropriate credit bureau report may be obtained. I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental history.
Signature (Patient or Parent/Guardian): ___________________________________ Date: ____________________________
Analgesics Fact Sheet Group 1: Traditional pain medications (called analgesics) These can be tried for usual acute pain or nociceptive pain, inflammatory pain and some of these might help neuropathic pain. Paracetamol Paracetamol is available from pharmacies as tablets, liquid mixtures, or suppositories. Often paracetamol is the sole chemical, but it is also used in o Paracetamol
Es importante que las personas desarrollen la habilidad de “redactar” textos, evitando así el plagio de información que más que una falta de irrespeto al derecho intelectual genera, en quienes copian, la pobreza de expresividad. Existen variadas técnicas para crear textos, en esta ocasión se recurrirá a una específica que tiene varios pasos; así: 1.- Escogemos el tema motivo d