Downtown Dentist - Charles E. Sutherland, DDS, PA

Downtown:

One Allen Center
500 Dallas Ste. P70
Houston, TX 77002 MAP
(866) 543-1909

Westchester:

West University
5252 Westchester at Bissonnet
Suite 200 Houston, TX 77005 MAP
(866) 543-1909

These forms have been designed to expedite the patient registration process once your appointment has been scheduled. The information provided here is kept strictly confidential and will not be shared with any third party carriers. If a particular field does not apply to you please enter "N/A" or "None."

All Fields are Required. Thank you.
Patient Information

* Address Me As:

* First Name:

Middle Initial:

* Last Name:

* Date of Birth:

* Social Security Number:

* Email Address:

Mailing Address:

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Work Phone:

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Student:

Yes

Enrollment Status:

Full

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Emergency Contact Information

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Billing Information

Only to be filled out if other than the patient

First Name:

Middle Initial:

Last Name:

Date of Birth:

Age:

Social Security Number:

Mailing Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Employer:

Dental Insurance Information
As a courtesy, we will accept payment of benefits directly from your insurance company. Please fill this part out accurately and completely. The part of our fee that is not covered by insurance is die at the time of treatment.

Name of Insurance Company:

Address of Insurance Company:

City:

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Zip Code:

Policy Holder´s Name and Relationship:

Policy Holder´s Social Security Number:

Policy Holder´s Date of Birth:

Policy Holder´s ID or Clock #:

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Name of Secondary Insurance Company:

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Policy Holder´s Social Security Number:

Policy Holder´s Date of Birth:

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Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a
physician’s care now:

Yes No

Have you ever been hospitalized or had a major operation:

Yes No

Have you ever had a serious head or neck injury:

Yes No

Are you taking medications, pills or drugs:

Yes No

Do you take, or have you taken, Phen-Fen or Redux:

Yes No

Are you on a special diet:

Yes No

Do you use tobacco:

Yes No

Do you use controlled substances:

Yes No

Are You:

Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
Not Applicable

Are you allergic to any of the following:

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
If other, please specify below

Do you have or have you had, any of the following:

AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Stomach / Intestinal Disease
Mitral Valve Prolapse
Swelling of Limbs
Thyroid Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Artificial Heart Valve
Easily Winded
Emphysema
Blood Disease
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack / Failure
Heart Murmur
Drug Addiction

Heart Trouble/Disease
Hemophilia
Epilepsy or Seizures
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Heart Peace Maker
Pain in Jaw Joints
Parathyroid Disease
Hepatitis A
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell
Sinus Trouble
Spina Bifida
Stroke
Artificial Joint
Asthma
Tonsillitis
Psychiatric Care
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice

Have you ever had any serious illness not listed above:

Please list any medications you are taking:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient’s) health, it is my responsibility to inform the dental office of any changes in medical status.

Dr. Charles Sutherland belongs to the DocShop network of cosmetic dentists. DocShop is a patient education resource that provides comprehensive information about tooth-colored fillings.

Downtown Dentist
Charles E. Sutherland, DDS, PA
Downtown: (866) 543-1909
Westchester: (866) 543-1909