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Kevin S. Brewer, D.M.D.
2505 Larkin Road, Suite 102
Lexington, KY 40503
(859) 277-7721
info.brewer.dental@gmail.com
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If
you have questions we will be glad to help you. We look forward to working with you in maintaining your dental health.
PATIENT INFORMATION
Date________________________ HomePhone (___)___________________________ CellPhone (___)____________________________
Name_________________________________________________________________ Preferred Name____________________________
Last Name First Name Initial
Married
Widowed
Single
Minor
Sex M F
Separated
Divorced
Partnered
Soc. Sec. #_______________________________
Age_________
Birthdate________________
Address_________________________________________________ E-mail_________________________________________________
City____________________________________________________ State___________________________ Zip____________________
Patient Employer/School___________________________________ Employer/School Phone (___)______________________________
Employer Address_____________________City/ST/Zip__________________ Occupation________________________________
In case of emergency who should be notified? _________________________________Phone (___)______________________________
REFERRAL INFORMATION
Whom may we thank for referring you to our practice?
Name of person or office referring you to our practice: ________________________________________________________________
PRIMARY DENTAL INSURANCE
Person Responsible for Account_____________________________________________________________________________________
Last Name First Name Initial
Relation to Patient_________________________________________ Birthdate_______________ ID#/Soc. Sec. #___________________
Address (If different from patient’s)___________________________________________________ Phone (___)_________________________
City_____________________________________________________ State_______________________________ Zip________________
Person Responsible Employed By____________________________ Occupation_____________________________________________
Business Address__________________________________________ Business Phone (___)_____________________________________
Insurance Company_______________________________________________________________________________________________
Contract #_______________________________________________ Group #_____________________ Subscriber #________________
Name of other dependents covered under this plan______________________________________________________________________
ADDITIONAL INSURANCE
Is patient covered by additional insurance? Yes No
Subscriber Name________________________________________ Relationship to Patient_________ ______Birthdate____________
Address (If different from patient’s)__________________________________________________ Phone (___)__________________________
City_____________________________________________________ State______________________________ Zip_________________
Subscriber Employed by___________________________________ Business Phone (___)_____________________________________
Insurance Company_______________________________________ Soc. Sec. #______________________________________________
Contract #______________________________________________ Group # ____________________ Subscriber #________________
Names of other dependents covered under this plan_____________________________________________________________________
Kevin S. Brewer, D.M.D.
2505 Larkin Road, Suite 102
Lexington, KY 40503
(859) 277-7721
info.brewer.dental@gmail.com
DENTAL HISTORY
Reason for Today’s Visit___________________________________________ Date of last dental care_____________________________
Former Dentist_________________________________________________ Date of last dental X-rays__________________________
Address__________________________________________________________________________________________________________
Check ( X ) if you have had problems with any of the following:
How often do you floss?___________________________________ How often do you brush?_________________________________
MEDICAL HISTORY
Physician’s Name_________________________________________ Date of Last Visit________________________________________
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin,
Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No
Have you had any serious illnesses or operations? Yes No
If yes, describe___________________________________________
Have you ever had a blood transfusion? Yes No
If yes, give approximate dates______________________________
Have you ever been told you need to take an antibiotic prior to a dental or surgical procedure?
Yes No
If yes, name of medication_________________________________
Are you pregnant?
Yes No
Nursing? Yes No
Taking birth control pills? Yes No
Check ( X ) if you have had problems with any of the following:
MEDICATIONS
ALLERGIES
List medications you are currently taking:
_________________________________________________________ ________________________________________________
_________________________________________________________ ________________________________________________ AUTHORIZATION
I certify that I, and/or my dependent(s), have insurance coverage with _______________________________________ and assign directly to Dr. Kevin S. Brewer all insurance
Name of Insurance Company(ies)
benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the
use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose
of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one
year from the date signed below.
___________________________________________________________
________________________________________ Signature of Patient, Parent, Guardian or Personal Representative ___________________________________________________________ ________________________________________ Print name of Patient, Parent, Guardian or Personal Representative PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED.

Source: http://www.kevinbrewerdmd.net/docs/Adult_Information_Form.pdf

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