BAY AREA ENDODONTICS, LLP
1550 S. HIGHLAND AVENUE, SUITE A • CLEARWATER, FL 33756 • TELEPHONE (727) 443-3231
PLEASE PRINT THE FOLLOWING INFORMATION
Patient ________________________________________________________________________________Dr.
Home Address __________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Other Address __________________________________________________________________________________________________
Employed by _______________________________________________ Occupation ______________________ Dept. ___________
Name of General Dentist _____________________________ Referred by (if different than general dentist): _____________________
Name of Spouse, Parent / Guardian _________________________________________
__________ S.S. No. _____________________
Employed by _______________________________________ Occupation ___________________ Bus. Phone # ________________
Name of Medical Physician _________________________________________________________ Phone ( _____ ) ______________
Cash ____ Check ____ Credit Card ____ Dental Insurance ____
Dental Insurance Information: Subscriber’s Name ___________________________ Birthdate __________ S.S. No. ______________
Insurance Company _____________________________ Policy No. __________ Group No. ___________ Phone ( _____ ) _____________
Insurance Address _______________________________________________________________________________________________
Secondary Insurance: Subscriber’s Name _________________________________ Birthdate __________ S.S. No. ______________
Insurance Company _________________________ Policy No. _____________ Group No. ____________ Phone ( ____ ) __________
Insurance Address ___________________________________________________________________________________________
In case of Emergency Notify ___________________________________ Relationship _____________ Phone _______________
PLEASE ANSWER ALL QUESTIONS
1. Are you now or have you been under the care of a physician in the past 2 years? .
2. Have you ever been hospitalized or had any operations? .
4. Do you need to premedicate with antibiotics before dental treatment for medical reasons? .
5. Have you experienced any unfavorable reaction to previous dental treatment? .
6. Please list any medications you are currently taking: __________________________________________________
7. Birth Control Pill users must use additional methods while taking antibiotics and for 72 hours afterward. 8. Check any you have had or currently have:
___ PENICILLIN OR OTHER ANTIBIOTICS (if yes, describe) ________________________________________________________________ XYLOCAINE OR OTHER DENTAL ANESTHETICS (if yes, describe) _______________________________________________________ CODEINE OR OTHER PAIN MEDICATION (if yes, describe) ___________________________________________________________
Date ______________ Signature __________________________________________________________________________________
Nutrition, Metabolism & Cardiovascular Diseases (2009) xx, 1e5a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o mComparison of the effects of cows’ milk, fortifiedsoy milk, and calcium supplement on weightand fat loss in premenopausal overweight andobese womenSh Faghih , A.R. Abadi , M. Hedayati S.M. Kimiagar a Department of Nutrition, Faculty of Nutrition Sciences and Fo
This test is due in class on Monday, December 6. Questions 1-5 are worth 2 points each. Circle the best answer. Justification is not required. 1. The stronger the linear relationship between paired-sample data X and Y, the closer the correlation coefficient is to +1 or -1. True 2. Suppose you calculate the correlation coefficient r between temperature X and volume Y. Then you recalculate
