East County Endodontics
Brian E. Hornberger D.D.S.. M.S.
3801 Lone Tree Way
Antioch, CA 94509

Email: info@eastcountyendo.com
Root Canal Hotline
(925) 753-5810
East County Endodontics
Brian E. Hornberger D.D.S.. M.S.
3801 Lone Tree Way
Antioch, CA 94509

Email: endo2@sbcglobal.net
Root Canal Hotline
(925) 753-5810
We shall take such good care of you today, that you will hesitate to leave our office for fear of a harsher world outside.

Page 1 of 4: Patient History Information

First Name
Last Name
SSN
Kaiser #
Gender
D.O.B.
Address
Apt#
City
Zip
Home # (xxx)xxx-xxxx
Cell # (xxx)xxx-xxxx
Work #
Email
Referring Dental Office
Employer Name
Employer Address
City & Zip
Emergency Contact
Emergency Phone #
Physician's Name
Physician's Phone #
If Student, School Name
If Minor, Parent/Guardian
Patient Medical History
Are you under any medical treatment at this time?
Within the past 5 years have you been hospitalized for any surgical operation or serious illness?
Are you currently taking any medication?
In case of medication needing to be prescribed. Which pharmacy do you prefer?
Do you use controlled substances?
Have you ever taken phen-phen?
Do you take a blood thinning medication?
Do you use tobacco?
Do you take insulin?
Have you ever taken bisphosphonates?
Are you allergic to any of the following?
Latex Rubber
Sulfa Drugs
Aspirin/Ibuprofen
Barbiturates(for insomnia, seizures, convulsions, anxiety)
Local Anesthetic
Sedatives
Metals
Penicillin
Iodine
Other Antibiotics
Other
Do you have a history of the following?
Heart Attack
Heart Murmur
Mitral Valve Prolapse
Sexually Transmitted Disease
Heart Disease
Cardiac Pacemaker
Joint Replacement/Implant
Diabetes
AIDS/HIV
Hepatitis
Jaundice
Asthma
Anemia
Angina
Emphysema
Cancer
Stroke
Liver Disease
Thyroid Problems
Radiation Therapy
Tuberculosis
Respiratory Problems
Fainting Seizures
Epilepsy/Convulsions
Kidney Disease
Stomach Ulcers
Blood Pressure
Other
*Women Only
Are you or might you be pregnant?
Are you nursing?
Are you taking oral contraceptives?
Method Of Payment
Patient Co-Payment must be paid in full at the time of treatment. How will you be paying today? ** NO CHECKS **
To apply for Care Credit click here.
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. I understand that providing false information can be dangerous to my health. I authorize the dentist to release information including diagnosis and records of treatment rendered to me or dependent to a third party payee &/or health practitioners. I authorize and request my insurance company to pay directly to Dr. Hornberger/East County Endodontics.
I understand that the insurance information provided to me is an estimate only and not a guarantee of payment. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Sign by entering your initials
 
Serving Contra Costa County, Antioch, Brentwood, Oakley, Discovery Bay, Bethel Isalnd, Pittsburg, Concord,