Anthony R. Cheslock D.D.S.
                 Patient Acquaintance Form

Name_________________________ Address ___________________________
City ____________ State _____ Zip __________ Home Phone _________
Work Phone __________  Sex (M/F) ____ Marital Status_____________
Birthdate _______ Social Sec. # _________________________________ 
Email ________________________________ Driv. Lic # ______________
Name of Responsible Party _______________________________________
Billing Address _________________________________________________
Insurance (Y/N)___ Employer Name __________ Phone _______________
Address ______________ City __________ State ____ Zip ___________
Insurance Company Name __________________ Phone _________________
Referred By _____________________________________________________
	CELL PHONE_________________

1. I HEREBY ASSIGN INS. BENEFITS TO THE ATTENDING DENTIST
   ___Yes___No
2. Are you in good Health?.	.	.	.     ___Yes___No
3. Are you under the regular care of a physician?.    ___Yes___No
4. Are you taking any medications regularly?.	.     ___Yes___No
5. List _________________________________________________________
DO YOU OR HAVE YOU EVER HAD:
6. Heart trouble (Palpitations, Angina, Rythm Problems Etc).
   ___Yes___No
7. Heart Murmur or heart valve problems.	.     ___Yes___No
8. Heart or blood vessel surgery.	.	.     ___Yes___No
9. Any type of joint surgery, replacement, or pins.   ___Yes___No
10. High or low blood pressure (circle).	.     ___Yes___No
11. Diabetes.	.	.	.	.	.     ___Yes___No
12. Rheumatic Fever.	.	.	.	.     ___Yes___No
13. Tuberculosis.	.	.	.	.     ___Yes___No
14. Asthma.	.	.	.	.	.     ___Yes___No
15. Hepatitis.	.	.	.	.	.     ___Yes___No
16. Bleeding Problems.	.	.	.	.     ___Yes___No
17. Do you have drug allergies (List) ___________________________
18. Ever had a reaction to local anesthetic such as novocaine?	
    ___Yes___No
19. Are you or is there a possibility you could be pregnant
    ___Yes___No
20. Have you been tested for the HIV virus?           ___Yes___No
      Date__________________________  Results ___________________
21. Is there any surgery or health treatment no mentioned?
    ___Yes___No
22. List ________________________________________________________
23. Physicians name and phone # _________________________________
24. Pharmacy name and phone # ___________________________________
25. In case of Emergency Notify Phone ___________________________
      Patient Signature ____________________ Date _______________
      Relationship to patient (Minors) __________________________