Reason for today’s visit: ______Date of last dental visit: ______
Former Dentist: ______Date of last dental x-rays: ______
Please complete the following and check accordingly:
□ Yes □ No Bad Breath □ Yes □ No Grinding Teeth □ Yes □ No Tooth sensitivity to cold
□ Yes □ No Bleeding Gums □ Yes □ No Loose Teeth □ Yes □ No Tooth sensitivity to sweets
□ Yes □ No Broken Fillings □ Yes □ No Periodontal Treatment □ Yes □ No Tooth sensitivity to heat
□ Yes □ No Clicking or Popping Jaw □ Yes □ No Sores or growths in your mouth
□ Yes □ No Food collection between teeth □ Yes □ No Sensitivity to biting
How often do you floss? ______How often do you brush: ______
2. Account Information/Dental Insurance
Who is responsible for this account? ______
Relationship to patient: ______
Insurance Company: ______
Insurance Phone #: ______
Subscriber’s Name: ______Birthdate: ______
Subscriber’s SS#/ID#: ______
Is the patient covered by additional insurance? □ Yes □ No
Insurance Company: ______
Insurance Phone #: ______
Subscriber’s Name: ______Birthdate: ______
Subscriber’s SS#/ID#: ______
3. Getting to know you
Is another family member a patient at our office? □Yes □No
Name: ______
How were you referred to us?______
Your former address: ______
City: ______State: ______Zip: ______
In case of emergency contact: ______
Phone #: ______
1. Patient Information
Name:______
Last First M.I.
Prefers to be called: ______
Nickname
Address: ______
City: ______State: ______Zip: ______
Home Phone: ______
Cell Phone: ______
Birthdate:______□Male □Female
□ Married □ Single □ Divorced
□ Widowed □ Child □ Other
Occupation: ______
Employer Name: ______
Employer Phone #: ______
Social Security #: ______
Driver’s License #:______
E-mail Address: ______
May we contact you by E-mail? □ Yes □ No
Please turn over and complete
5. Medical HistoryPhysician’s Name: ______Date of last visit: ______
Have you ever taken any of the group of drugs referred to as “Fen-Phen”? These include Ionimin, Apidex, Fastin (brand of Phentermine), Pondimin (Feniluramine), and Redux (Dexfenfluramine): □ Yes □ No
Do you have any auto-immune diseases? □ Yes □ No If yes, describe: ______
Have you ever had any serious illness or operation? □ Yes □ No If yes, describe: ______
Have you ever had a blood transfusion? □ Yes □ No If yes, approximate date(s): ______
Have you ever had Botox or Fillers? □ Yes □ No If yes, approximate date(s) ______
(Women) Are you pregnant? □ Yes □ No Nursing? □ Yes □ No Taking birth control? □ Yes □ No
7. Medications (List all you are currently taking)
______
______
______
8. Allergies: / Are you allergic to Latex? □ Yes □ No
(List any other allergies): ______
______
______
9. Authorization and Release
· I am aware that the office requires 24 hour business notice when canceling or rescheduling appointments. I understand there is a charge of $30 per half hour scheduled for the appointment cancelled/rescheduled without proper notice.
· I authorize the Dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
· I agree to use of anesthetics, sedatives, and other medications as necessary. I fully understand that using anesthetic agents embody certain agents. I understand that I can ask for a complete recital of any possible complications.
· I authorize the dentist and/or the staff to share any necessary information to specialty offices unless otherwise stated by me.
· I agree to be responsible for payment of all services rendered on my/my dependents behalf. I understand that payment is due at the time of service (unless other arrangements have been made). In the event that payments are not received by agreed upon dates, I understand a 1 1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
· I understand if a check I have written for payment does not clear through my banking institution the office will re-instate the amount of the check as well as apply a $25.00 charge to my account or up to 10x the amount of the check.
· As a courtesy, I understand the staff will bill my dental insurance, if I have one. I also understand that all estimates quoted by the dentist and/or staff and through my insurance are not a guarantee of payment and anything my insurance does not cover is my responsibility.
Signature patient/guardian: ______Date: ______
Dentist Signature: ______Date: ______
6. Health History please read carefully and check accordingly, be sure to checkmark each item i.e. ¨ Yes þ No
□ Yes □ No Anemia / □ Yes □ No Glaucoma / □ Yes □ No Rheumatic fever / □ Yes □ No Artificial heart valves
□ Yes □ No Arthritis / □ Yes □ No Headaches / □ Yes □ No Scarlet Fever / □ Yes □ No Artificial joints/implants
□ Yes □ No Asthma / □ Yes □ No Heart Murmur / □ Yes □ No Skin Rash / □ Yes □ No Chemical Dependency
□ Yes □ No Back Problems / □ Yes □ No Hemophilia / □ Yes □ No Stroke / □ Yes □ No Circulatory problems
□ Yes □ No Blood disease / □ Yes □ No Hepatitis / □ Yes □ No Thyroid problems / □ Yes □ No Persistent cough
□ Yes □ No Cancer / □ Yes □ No HIV/Aids / □ Yes □ No Tobacco habit / □ Yes □ No High blood pressure
□ Yes □ No Chemotherapy / □ Yes □ No Jaw pain / □ Yes □ No Tonsillitis / □ Yes □ No Mitral valve prolapse
□ Yes □ No Cortisone TX / □ Yes □ No Kidney disease / □ Yes □ No Tuberculosis / □ Yes □ No Radiation treatment
□ Yes □ No Diabetes / □ Yes □ No Liver disease / □ Yes □ No Ulcer / □ Yes □ No Respiratory disease
□ Yes □ No Epilepsy / □ Yes □ No Migraines / □ Yes □ No Venereal disease / □ Yes □ No Shortness of breath
□ Yes □ No Fainting / □ Yes □ No Pacemaker / □ Yes □ No Cough up blood / □ Yes □ No Infective Endocarditis