Sebastian Bouroncle DDS
1900 Opitz Blvd. Suite C
Woodbridge, VA 22191.
Ph: (703) 494-0820
Welcome! Thank you for selecting our dental office. To help us meet all your health care needs, please complete this form as accurately as possible. 1) Patient full name: _________________________________ Social Security # ________________________ Birth Date: ________________________________________ Address: __________________________________________ City: ______________ State ______Zip C ____________ Full Time Student: __________________________________ School Name: __________________________________ Employer : ________________________________________ Occupation: ___________________________________ Previous Dentist : ___________________________________ Previous Dentist Phone: __________________________ Current Physician: __________________________________ Physician Phone #: ______________________________ How did you hear about our office? ________________________________________________________________________ Home Phone: ______________________ Work Phone: ________________________ Cell # _________________________ Email: ______________________________________________________ In case of an emergency, who should we contact? Name: ______________________________________ Relationship: ___________________________________ Home Phone: ________________________________ Cell #: ________________________________________ Who is responsible for this patient? ________________________ Social Security # _______________________________________ Birth Date: ____________________________________ Address: _____________________________________________ City: ________________ State ______ Zip C _________ Employer: ____________________________________________ Home Ph: ________________ Work Ph: _____________ Name of Ins. Holder: ___________________________________ Relationship:________________________________ Insured’s SSN : ________________________________________ Birth Date: _________________________________ Ins. Company name: _________________________ ___________ Employer: __________________________________ Group # ________________________________ Ins. Phone Number ___________________________ ID # __________________________________ Do you consider yourself in good medical health? Do you smoke or use tobacco in any forms Do you have any metal rods, pins or Orthopedic Implants? Are you taking any prescription/over the counter or herbal supplemental drugs? Please list all medications currently taken: ______________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________. Have you ever taken Fosamax, Actonel, Boniva, Didronel, Skelid or any medication for Osteoporosis? Do you take any Blood thinners (Aspirin, Plavix, Coumadin…)? If Pregnant, week # _____________________ Do you take Birth Control Rx.? Have you ever had any of the following medical problems? Abnormal bleeding Are you allergic to the following: Aspirin Please list any other drugs/materials that you are allergic to: __________________________________________ ________________________________________________________________________________________. 6) What is the reason for your visit today? __________________________________________________________________ Do you require antibiotics before dental treatment? Have you ever had difficulties associated with any previous Dental work? Have you ever had pain in your jaw joint (TMJ/TMD)? How many times a week do you floss? ________________________ Are your teeth sensitive to hot, cold or both? When was the last time you had a cleaning? ____________________ I understand that the information I have given today is correct to the best of my knowledge, I also understand that this information will be held in confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need. ___________________________________


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