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$14.83 /month

Additional Adult

Add any patient aged 13 years up to an existing Individual plan

$14.83 /month

Additional Adult

Add any patient aged 13 years up to an existing Individual plan

$14.83 /month

Additional Adult

Add any patient aged 13 years up to an existing Individual plan


    Step 1

    Responsible Party ( if someone other than the patient )

    Patient Information

    Section 2

    Section 3

    Primary Insurance Information


    Ins. Company

    Secondary Insurance Information


    Ins. Company

    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,could have an important interrelationship with the dentistry you will receive. Thank you for answering the following features.

    Women: Are you.....

    Allergic to any of the following?

    Do you have, or have you had, any of the following?

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my(or patient's) health. It is my responsibilties to inform the dental office of any changes in medical status

    Step 2


    CONSENT FORM, If applicable:

    Consent to receive dental treatment: I hereby consent and authorize the doctors and staff members to examine, clean and provide dental treatment to my child. I further consent and authorize the taking of dental x-rays, as they may be considered necessary to diagnose and/or treat my child.
    Minor Drop-Off Consent: In the event I drop off my minor child to receive dental services, I hereby consent the doctors and staff, to clean and provide dental treatment to my child. I have listed a contact person to be reached in case of emergency below:


    I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I acknowledge that all financially responsible parties are to be present for all treatment planning and financial estimates. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance. In the event my account balance remains unpaid in excess of 90 days, I understand that my account will be turned over to a collections agency. I accept full responsibility for all administrative costs and legal fees associated with the collections process. I agree to
    reimburse the fees of any collection agency, which may be based on a percentage at a maximum of 54% of the debt, and all costs and expenses, including reasonable attorney’s fees that the dental office incurs in such collection efforts.

    I understand that there is a broken appointment policy and I may be charged $40, unless I notify the office within 2 business days of my cancellation.

    For your convenience our office takes personal checks. However, I understand a $50 fee will be applied to my account for a bounced check (NSF) and from that point forward, personal checks will no longer be acceptable form of payment.


    I, the undersigned, have insurance with and I authorize my insurance company to assign benefits directly to my dental provider, 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 within 30 days from the date of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.


    By signing below, I hereto irrevocably waive any and all right to trial by jury in any legal proceeding arising out of or related to this agreement or any treatment services provided by offices affiliated with Narducci Dental Group, P.A., its associates, shareholders, and employees. The scope of this waiver is intended to be all-encompassing of any and all disputes that may be filed in any court and that relate to the subject matter of this agreement.

    By signing below, I accept the above terms set forth by the dental office and acknowledge full understanding of said terms.


    You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

    It is very important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instruction, referrals to other dentists or specialist, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

    Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition, advise your dentist immediately so your physician can be consulted if necessary.

    If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.

    As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.

    Some of the more commonly known risks and complications of treatment include, but are not limited to the following:

    1. Pain, swelling, and discomfort after treatment.
    2. Infection in need of medication, follow-up procedure or other treatment.
    3. Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste.
    4. Damage to adjacent teeth, restorations, or gums.
    5. Possible deterioration of your condition which may result in tooth loss.
    6. The need for replacement of restoration, implants or other appliances in the future.
    7. An altered bite in need of adjustment.
    8. Possible injury to the jaw and related structures requiring follow up care and treatment, or consultation by a dental specialist.
    9. Root tip, bone fragment or a piece of dental instrument may be left in your body, and may have to be to be removed at a later time if symptoms developed.
    10. Jaw fracture.
    11. If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for future treatment.
    12. Allergic reaction to anesthetic or medication.
    13. Need for follow up treatment, including surgery.

    This form is intended to provide you with an overview of potential risks and complications. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.


    COVID CONSENT FORM, If applicable:

    I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

    To proceed with receiving care, I confirm and understand the following (Initial in all four places provided)

    Initial Below

    1) I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted.

    2) I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.

    3) I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below:
    *Fever *Shortness of Breath *Dry Cough *Runny Nose *Sore Throat *Loss of Taste or Smell

    4) I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.



    Step 3

    Your Notice of Privacy Practices

    HIPAA policy


    I, , hereby acknowledge that I have received and reviewed a copy of Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of Privacy Practices.

    I understand that Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of
    Privacy Practices may change periodically and that I am entitled to receive a copy of Narducci
    Dental Group, P.A., and affiliated dental practices revised HIPAA Notice of Privacy Practices
    upon request.

    I understand that, if I have questions about Narducci Dental Group, P.A., and affiliated dental
    practices HIPAA Notice of Privacy Practices, I may contact Narducci Dental Group, P.A., at (904)

    I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and
    that Narducci Dental Group, P.A. and affiliated dental practices will not refuse treatment to me if I
    refuse to sign this Acknowledgement.

    I further understand that I may contact the Secretary of the U.S. Department of Health and
    Human Services should I have concerns regarding Narducci Dental Group, P.A. and affiliated
    dental practices privacy policies and procedures. For information on how to contact the U.S.
    Department of Health and Human Services, please ask Narducci Dental Group, P.A., at (904)
    998-7000, noted above, for assistance.



    Bisphosphonates are a type of drug given to millions of Americans to treat osteoporosis or as part of cancer treatment, namely for breast cancer, lung cancer, prostate cancer, multiple myloma, Paget’s disease of the bone, alveolar necrosis of the bone or post￾menopausal osteoporosis. They are sometimes given orally and other times are given through people’s veins. Some of the common names include but are not limited to:

    1. Actonel (Risedronate)
    2. Bonefos (Clodronate)
    3. Fosamax (Alendronate)
    4. Fosamaz Plus D (Alendronate)
    5. Aredia (Pamidronate)
    6. Didronel (Etidronate)
    7. Boniva (Ibandronate)
    8. Ostac
    9. Skelid (Tiludronate)
    10. Zometa (Zolendronic Acid)
    11. Pamidronate

    In rare instances, some people on these drugs have developed a condition called Osteonecrosis of the jaw, which results in severe damage to or loss of the jaw bone. Symptoms include but are not limited to pain, swelling or infection of the gums or jaw, gums that are not healing, loose teeth, numbness or a heavy feeling in the jaw, drainage and exposed bone. There is no proven treatment to fix this problem.

    Accordingly, patients on these drugs should know the risks, benefits, and alternatives of invasive dental procedures. If a patient is on Bisphosphonates, your dentists, follows special procedures to promote the safety of the patient. It is very important that you let the dentist know whether you are taking any medications, particularly a Bisphosphonates drug, or if you have ever taken a Bisphosphonate drug. If you are not sure if the drugs you are taking are Bisphosphonates, ask the dentist. You have a duty and responsibility to tell the dentist all the drugs that you take.

    I hereby disclose that:

    It is called:
    I have taken this medication for: (Amount of time)



    Consent To receive text message and electronic communication alerts

    We have the ability to send text and email messages to your provided cell phone number to receive account information such as appointment reminders, appointment openings, account updates, marketing specials, opportunities, and other alerts

    Please indicate below whether you would like to receive text and email confirmation,reminders,newsletters,specials, and other updates. Text message charges from your cell phone provider may apply.

    By signing below, I wish to enroll in the text message and email alert communication explained above

    You can withdraw your consent at any time by calling the office. You are responsible providing updates to your cell phone and email information

    It is important to note that text communication is not always secure. Text messages can be intercepted and for this reason, we do not communicate personal health information through this method.

    Step 4

    Membership Terms

    Please Read Carefully

    This discount program is NOT a dental insurance policy, health insurance policy, or a Medicare prescription drug plan and does not make payments directly to service providers. Members are obligated to pay for all services. Members will receive discounts on dental services from participating providers and the discount range will vary on provider and dental services received. The program does not constitute minimum creditable coverage under Florida Law or the Affordable Health Care Act. Program is administered by ProActive Dental Solution, a partner of Narducci Dental Group, P.A., (T) 904.998.7000.


    An “adult member” and /or “adult addition” is defined as any person being eighteen (18) years of age and older at time of enrollment.

    A “child member” and /or “child addition” is defined as any person being seventeen (17) years of age and younger at time of enrollment. A primary child member (in the absence of and adult enrollee), shall be considered an “individual” in terms of the membership fees.

    Member Terms and Conditions

    This program is not insurance. It is a discount membership program offered by ProActive Dental Solution. ProActive Dental Solution is not a licensed insurer, health maintenance organization, or other underwriter of dental health care services. Discounted providers are solely in the practice of dentistry and do not provide medical procedures.

    The savings are based upon the provider’s normal fees. Actual savings will vary depending upon the location. Please verify services with each individual provider. The discount herein may not be used in conjunction with any other discount, coupon, voucher, promotion plan or program. All listed or quoted prices are subject to change without notice. Any procedures performed by an outside provider are not discounted. Discounts on professional services are not available where prohibited by law. Treatment may require more than one procedure listed in the treatment plan.

    Providers are subject to change without notice. It is the Member’s responsibility to verify that the provider is a participating provider of ProActive Dental Solution. At any time, ProActive Dental Solution has the right to eliminate the provider from the provider network. In the event of the eliminated provider, you will need to select another provider.

    Providers of ProActive Dental Solution are solely responsible for the professional advice and treatment provided to Members and the ProActive Dental Solution disclaims any liability with respect to such matters. Services and service providers may change or be discontinued at any time without notice.You agree that you may not amend or modify this Agreement with any restrictive endorsements (such as “paid in full”), or other statements or releases on or accompanying checks or other payments accepted by ProActive Dental Solution and any such notations shall have no legal effect.


    The initial term of this agreement is one (1) year commencing on the effective date and shall automatically renew thereafter on a monthly basis, unless either party gives written notice of non￾renewal (via mail or email) to the other at least thirty (30) business days, but no more than sixty (60) days prior to the expiration of the current term.

    Due Date

    If you select to make monthly payments, please note your due date will be exactly one month from your enrollment date for a total of 12 months (i.e. You enrolled on January 15th, your monthly due date would be the 15th of each month). The same date will be used for all month-to month memberships following a one (1) year initial term.

    If you elect to pay the initial one (1) year term in full, the due date is the date of enrollment.

    Payment Obligations

    On your due date, we will deduct your Automatic Pay Plan payment from the payment account you designated. Automatic payments will be debited from your bank account on the payment due date indicated on your pay plan agreement. This will occur even if you elect to make additional payments outside of the Automatic Payment, or request an Automatic Payment amount that is greater than your contracted payment amount. Your Automatic Payment Due date will be your contractual due date. If Automatic Payments cannot be established as requested, you will be contacted via the phone numbers provided on the application or by e-mail with a brief explanation of any issues. This may cause a delay in set up of your Automatic Payments. You will still be responsible to make payments until automatic payments have been established.

    Check with your financial institution to determine if any additional charges for such a debit will apply to your account and ask how it will note descriptions of automatic debits on your statement. If the transaction is refused by your financial institution for any reason, including insufficient funds, closed account, or unauthorized account, we will not be able to process your payment. Your account may be subject to additional charges if your payment is rejected, reversed or refused by your financial institution.

    If ProActive Dental Solution receives notice that your Deposit account has been closed or frozen, or is an invalid number, you may be assessed a fee which will be added to your next scheduled payment. You agree to pay all amounts due upon demand.

    Changing Contractual Due Date

    Please contact ProActive Dental Solution with a written request to change the date of the contractual due date and/or Automatic Payment date.

    To Cancel Automatic Payments

    ProActive Dental Solution must be notified at least 30 days prior to the applicable payment date by written notice. If the Automatic Payment is not cancelled in time, the system will still debit the payment from your Deposit account or be subject to a rate increase if Automatic Payments are cancelled.


    To cancel an Automatic Pay Plan withdrawal, you will need to notify us at least 30 business days before the transaction is scheduled to be made. Your Automatic Pay Plan program enrollment will remain active and in effect unless we receive a cancellation notice thirty (30) days in advance of when the automatic payment is scheduled to be withdrawn. The written notice may be mailed to our office at 3545 St. Johns Bluff Road South, #352, Jacksonville, FL 32244 or emailed to Every effort will be made to honor requests. Upon written request, automatic debit service will be cancelled as soon as possible. If a Member terminates this agreement other than as above, or if ProActive Dental Solution terminates due to Member’s breach (including nonpayment), Member shall pay ProActive Dental Solution the amount equal to the remaining payments of the one (1) year term at time of cancellation. If Member no longer required services during a month-to-month period following an initial term then Member may terminate this agreement by providing thirty (30) -day prior written notice and paying all amounts due up to termination.

    Services Provided Under This Contract

    Including but not limited to: Periodontal Maintenance/ Prophylaxis: both services are covered at no additional charge when performed six months apart within a qualifying active year of Membership, not to exceed two (2) services per active year of membership. Member shall be responsible for all charges and fees exceeding this limitation.

    Panoramic Radiographs: Is not a discounted service when performed on the same day as a Full Mouth Series of radiographs (procedure code D0210).

    Excluded Services:

    Fluoride, Oral Cancer Screenings, Whitening products, and other products offered by the provider’s office for purchase are not covered by the Proactive Dental Solution Dental Discount Membership, such may be purchased at fees determined by the provider.

    Unauthorized Use:

    If you think your account has been accessed without your permission, contact us immediately by calling or writing us at our telephone number. You should also contact your financial institution. Call us immediately if any unauthorized payments appear on your bank account statement.


    We may share information we collect about you, except credit bureau information, with outside
    companies that are assisting us with servicing your account. Our agreements with these outside
    companies (service providers) require that they protect this information; they are only to use it to carry out the services they are performing for us.

    Waiver of Rights:

    We do not waive our rights to collect the full balance owed to us by accepting partial payment. We will apply the partial payment to the outstanding charges in the amounts and proportions that we determine.

    Disputes, Arbitration, Jury Trial and Class Action Waiver

    Except for claims by Proactive Dental Solution for collection of its fees, the parties knowingly, voluntarily and irrevocably agree that at the election of either party any controversy arising between them (WHETHER RELATED TO THIS AGREEMENT OR ANY PRIOR AGREEMENT) shall be resolved by BINDING ARBITRATION under the rules of the American Arbitration Association governed by and enforceable under the Federal Arbitration Act, and judgment on the award may be entered by any court having jurisdiction. Member acknowledges the service ProActive Dental Solution provides to it impacts interstate commerce and agrees that any dispute about the enforceability or scope of the agreement to arbitrate shall be decided by the arbitrator. The parties’ mutual promises contained herein, including to arbitrate certain disagreements, rather than litigate them before courts or other bodies, provides adequate consideration therefore. THE PARTIES EACH HEREBY WAIVE TRIAL BY JURY IN ANY ACTION PROCEEDING, COUNTERCLAIM OR CROSS-CLAIM BROUGHT BY ANY OF THEM AGAINST THE OTHER WHETHER IN ARBITRATION OR AS OTHERWISE EXCEPTED ABOVE AND FURTHER WAIVE THE RIGHT TO PARTICIPATE AND/OR BE REPRESENTED IN ANY CLASS ACTION, ANY ACTION ON A CONSOLIDATED BASIS OR ANY OTHER COLLECTIVE OR REPRESENTATIVE PROCEEDING. THE PARTIES AGREE THAT NO ACTION MAY BE MAINTAINED AS A CLASS ACTION OR PURSUED ON A CONSOLIDATED BASIS IN ARBITRATION OR OTHERWISE. Any action (including arbitration) by Member against ProActive Dental Solution whether related to this Agreement or any prior Agreement, must be brought within 1 year of the date of any alleged wrongful act. Any proceedings shall be conducted in the location where services are rendered by ProActive to the Member and governed by the laws of the state. Member shall notify ProActive Dental Solution in writing of any alleged breach by ProActive Dental Solution of this Agreement and allow Proactive Dental Solution at least 10 business days to cure the same. If any proceeding is brought by Proactive Dental Solution in connection with this Agreement ProActive Dental Solution shall be entitled to recovery its legal fees and costs leading up to the and incurred in that action in addition to any other relief to which it may be entitled. ProActive Dental Solution shall not be liable for any indirect, incidental or consequential damages and its aggregate liability, if any, arising out of this Agreement shall not exceed the aggregate fees paid to ProActive Dental Solution by Member, regardless of the recovery sought. This paragraph and Member’s representations, warranties, and indemnification shall survive termination of the Agreement.

    By signing below, I acknowledge I have read, understand, and accept all the terms and conditions set forth herein. By purchasing a Membership I agree to be bound by these terms, which outline, among other things, the cancellation policy.

    Patient Registration Form

    Patient Id: :   [patient-id] Chart Id:   [chart-Id] Patient Is:   [Pateint-Is] Preferred Name:   [Preferred-Name]
    FirstName:   [FirstName] Middle Name:   [MiddleName] LastName:  [LastName]
    Responsible Party ( if someone other than the patient )
    FirstName: :   [Responsible_Party_FirstName] Middle Name:   [Responsible_Party_MiddleName] LastName:   [Responsible_Party_LastName] [Address]:   [Responsible_Party_Address]
    Address2:  [Responsible_Party_Address2] City:   [Responsible_Party_Citystarting] State:   [Responsible_Party_State] Zipcode:   [Zipcode_responsible_party]
    Pager:  [Responsible_Party_Pager] Home Phone:   [Responsible_Party_home-phone] Work Home:   [Responsible_Party_work-phone] Ext:   [Responsible_Party_Ext]
    Birth Date:  [Responsible_Party_DOB] SOC SEC:   [Responsible_Party_Socsection] Drivers LIC:   [Responsible_Party_Drivers] Policy Holder:   [policyholder]
    Patient Information
    Address:  [PatientAddress] Address2:   [PatientAdress2] City:   [PatientCity] State:   [PatientState]
    Zip-Code:  [PatientZipcode] Patient Pager:   [PatientPager] Home Phone:   [Patienthome-phone] Work Phone:   [Patientwork-phone]
    Ext:  [EPatientxt] Birth Date:   [PatientDOB] SOC Sec:   [PatientSocsection] Drivers LIC:   [PatientDriversLic]
    Age:  [Patientage] Sex:   [PatientSex] Marital Status:   [PatientMaritalStatus] Email:   [EmailPatient]
    Section 2
    Employment Status:  [EmploymentStatus:] Student Status:   [StudentStatus:] Medical ID   [MedicalId] Employeer Id:   [EmployeerId]
    Carrier Id:  [CarrierId] Pref Dentist:   [PrefDentist] Pref Pharmacy  [PrefPharmacy] Pref Hyg:   [Pref]
    Section 3
    Referred By:  [ReferredBy] Previous Dentist:   [PreviousDentist] Last Dental Exam   [LastDentalExam]
    Primary Insurance Information
    Name of Insured:  [nameofinsuranced] Relationship to Insured:   [RelationshiptoInsured] Insured Soc. Sec:   [InsuredSoc] Insured Birth Date:  [InsuredBirthDate]
    Employer:  [InsuranceEmployer] Address:   [Address_Employer_Insurance] Address 2:   [Adress2_Employer_Insurance] City:  [InsuranceCityEmployer]
    State:  [InsuranceStateEmployer] Zip code:   [InsuranceZipcodeEmployer] Rem Benefits:   [RemBenefitsemployeer] Rem Deduct:   [RemDeductemployeer]
    Ins. Company:  [insCompany] Address:   [ins_Address_Company] Address 2:  [Adress2_Company_ins] City:   [CityCompanyins]
    State:  [StateCompanyins] Zip code:   [ZipcodeCompanyins] Rem Benefits:   [RemBenefitsins] Rem Deduct:   [RemDeductins]
    Secondary Insurance Information
    Name of Insured:  [nameofinsurancedSecondary] Relationship to Insured:   [RelationshiptoInsuredSecondary] Insured Soc. Sec:   [InsuredSocSecondary] Insured Birth Date:  [InsuredBirthDateSecondary]
    Employer:  [EmployerSecondary] Address:   [Address-EmployerSecondary] Address 2:   [Adress2-EmployerSecondary] City:  [CityEmployerSecondary]
    State:  [StateEmployerSecondary] Zip code:   [ZipcodeEmployerSecondary] Rem Benefits:   [RemBenefitsSecondary] Rem Deduct:   [RemDeductSecondary]
    Ins. Company:  [CompanySecondaryins] Address:   [Address_CompanySecondaryins] Address 2:  [Adress2_CompanySecondaryins] City:   [CityEmployerSecondaryins]
    State:  [StateEmployerSecondaryins] Zip code:   [ZipcodeEmployerSecondaryins] Rem Benefits:   [RemBenefitsSecondaryins] Rem Deduct:   [RemDeductSecondaryins]
    Health problems (Yes/no)
    Are you under a physician's care now?  [physician]
    Ifyes:   [ifyesphysician]
    Have you ever been hospitalized or had a major operation?  [operationhospitalized]
    Ifyes:   [ifyeshospitalized]
    Have you ever had a serious head or neck injury?  [neckinjury]
    Ifyes:   [neckinjuryyes]
    Are you taking any medications, pills, or drugs?  [drugs]
    Ifyes:   [drugsyes]
    Do you take, or have you taken, Phen-Fen or Redux?  [Redux]
    Ifyes:   [ifyesRedux]
    Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?  [bisphosphonates]
    Ifyes:   [ifyesbisphosphonates]
    Are you on special diet?  [specialdiet]
    Ifyes:   -
    Do you use tobacco?  [tobacco]
    Ifyes:   -
    Women: Are you.....
    Women: Are you.....  [Womenareyou] ALLERGIC TO ANY OF THE FOLLOWING?  [allergic-to-any]
    Do you have, or have you had, any of the following?
    AIDS/HIV Positive  [HIVPositive] Cortisone Medicine  [CortisoneMedicine] Hemophilia  [Hemophilia] Radiation Treatments  [RadiationTreatments]
    Alzheimer's Disease  [AlzheimersDisease] Diabetes  [Diabetes] Hepatitis A  [HepatitisA] Recent Weight Loss  [RecentWeightLossy]
    Anaphylaxis  [Anaphylaxis] Drug Addiction  [DrugAddiction] Hepatitis B or C  [HepatitisB] Renal Dialysis  [RenalDialysis]
    Anemia  [Anemia] Easily Winded  [EasilyWinded] Herpes  [Herpes] Rheumatic Fever  [Rheumaticfever]
    Angina  [Angina] Emphysema  [Emphysema] High Blood Pressure  [bloodpressure] Rheumatism  [Rheumatism]
    Arthritis/Gout  [ArthritisGout] Epilepsy or Seizures  [Epilepsy] High Cholesterol  [Cholesterol] Scarlet Fever  [ScarletFever]
    Artificial Heart Valve  [ArtificialHeartValve] Excessive Bleeding  [ExcessiveBleeding] Hives or Rash  [HivesorRash] Shingles  [Shingles]
    Artificial Joint  [ArtificialJoint] Excessive Thirst  [ExcessiveThirst] Hypoglycemia  [Hypoglycemia] Sickle Cell Disease  [SickleCellDisease]
    Asthma  [Asthma] Fainting Spells/Dizziness  [Dizziness] Irregular Heartbeat  [Heartbeat] Sinus Trouble  [SinusTrouble]
    Blood Disease  [BloodDisease] Frequent Cough  [FrequentCough] Kidney Problems  [KidneyProblems] Spina Bifida  [SpinaBifida]
    Blood Transfusion  [BloodTransfusion] Frequent Diarrhea  [Diarrhea] Leukemia  [Leukemia] Stomach/Intestinal Disease  [IntestinalDisease]
    Breathing Problems  [BreathingProblems] Frequent Headaches  [Headaches] Liver Disease  [LiverDisease] Stroke  [Stroke]
    Bruise Easily  [BruiseEasily] Genital Herpes  [GenitalHerpes] Low Blood Pressure  [LowBloodPressure] Swelling of Limbs  [SwellingofLimbs]
    Cancer  [Cancer] Glaucoma  [Glaucoma] Lung Disease  [LungDisease] Thyroid Disease  [ThyroidDisease]
    Chemotherapy  [Chemotherapy] Hay Fever  [HayFever] Mitral Valve Prolapse  [MitralProlapse] Tonsillitis  [Tonsillitis]
    Chest Pains  [ChestPains] Heart Attack/Failure  [HeartAttack] Osteoporosis  [Osteoporosis] Tuberculosis  [Tuberculosis]
    Cold Sores/Fever Blisters  [ColdSoresBlisters] Heart Murmur  [HeartMurmur] Pain in Jaw Joints  [PaininJawJoints] Tumors or Growths  [TumorsorGrowths]
    Congenital Heart Disorder  [Congenital] Heart Pacemaker  [Pacemaker] Parathyroid Disease  [Parathyroid] Ulcers  [Ulcers]
    Convulsions  [Convulsions] Heart Trouble/Disease  [HeartTrouble] Psychiatric Care  [Psychiatric] Venereal Disease  [VenerealDisease]
    Have you ever had any serious illness not listed  [anyseriousillness]
    If Yes:    [anyseriousillnessifyes]
    Comment  [Comment] Date  [DateOfissue]
    Agreement Name  [agreementName] Agreement Phone  [agreementPhone] Relationship  [agreementRelationship] Agreement date  [DateOfissue]
    Insurance Name  [insurancename] Print Patient Name  [printpatientname] Parent/Legal Guardian  [ParentGuardian] minorPatientDate  [minorPatientDate]
    Patient Date  [PatientDate] Agreement Darte  [agreementDate]
    Acknowledgement Name  [acknowledgement-name] Acknowledgement Date  [DateAcknowledgement] Discloser Name   [disclosename] Discloser Past Name   [disclose-past-name]
    Disclose Name  [disclosename] Disclose Past Name  [disclose-past-name] Medication Name   [medication-name] Medication Past 2   [medication-name2]
    Disclose Print Name  [disclosePrintName] Disclose Print Date  [disclosePrintDate] Disclose Print Name 2   [disclosePrintName2] Disclose Print Date 2   [disclosePrintDate2]