515-288-0433 * Fax: 515-288-0643 Dr. Larry Nelson, DDS e-mail: info@drlarrynelson.com Family Dentistry office cell for emergencies: 515-468-0199 215 10th Street, Suite 210 * Des Moines, IA 50309 MEDICATION or Latex First Name: Allergies (Please List): Middle: Last Name: Nick Name: Primary Doctor Info: Address: Name: City: Address or State: General Location: Phone: Birthdate: Pharmacy Info: Pharmacy Name: Driver’s License #: Address or Male: Female: Employer: General Location: School: Phone: Email (for recall reminders twice a year) Dental Insurance Policyholder Information: Home Phone: (If you have an insurance card, you don't need to fill out Cell Phone: this section. We will make a copy.) Okay to send text? (for Insurance Company: making appointments, etc.) Subscriber ID/SSN: Work Phone: Policyholder's 1st Name: Policyholder's Middle: Spouse/Partner First Name: Policyholder's Last Name: Spouse/Partner Last Name: Policyholder's Birth date: Emergency Contact: Policyholder's Employer: Emergency. Contact Phone: Group Plan ID: 2nd Dental Insurance Policyholder Info: Do you have metal in your body or Insurance Company: a mitral valve prolapse or any other Subscriber ID/SSN: reason you need antibiotics before Policyholder's 1st Name: dental work? Please explain? Policyholder's Middle: Policyholder's Last Name: If you are currently pregnant, what Policyholder's Birth date: is your due date? Policyholder's Employer: Group Plan ID: Prescription Medications: Non-prescription Medications:
First Name: Middle: Last Name: Nick Name: Address: City: State: Birthdate: Driver’s License #: Male: Female: Employer: School: Email (for recall reminders twice a year) Home Phone: Cell Phone: Okay to send text? (for making appointments, etc.) Work Phone: Spouse/Partner First Name: Spouse/Partner Last Name: Emergency Contact: Emergency. Contact Phone: Do you have metal in your body or a mitral valve prolapse or any other reason you need antibiotics before dental work? Please explain? If you are currently pregnant, what is your due date? MEDICATION or Latex Allergies (Please List): Primary Doctor Info: Name: Address or General Location: Phone: Pharmacy Info: Pharmacy Name: Address or General Location: Phone: Dental Insurance Policyholder Information: (If you have an insurance card, you don't need to fill out this section. We will make a copy.) Insurance Company: Subscriber ID/SSN: Policyholder's 1st Name: Policyholder's Middle: Policyholder's Last Name: Policyholder's Birth date: Policyholder's Employer: Group Plan ID: Dr. Larry Nelson, DDS Family Dentistry 215 10th Street, Suite 210 * Des Moines, IA 50309 515-288-0433 * Fax: 515-288-0643 e-mail: info@drlarrynelson.com office cell for emergencies: 515-468-0199 2nd Dental Insurance Policyholder Info: Insurance Company: Subscriber ID/SSN: Policyholder's 1st Name: Policyholder's Middle: Policyholder's Last Name: Policyholder's Birth date: Policyholder's Employer: Group Plan ID: Prescription Medications: Non-prescription Medications:
healthhistoryform2015.docx