Abel, Phan & Associates / Loudoun Dental Arts, D.D.S., PLLC
Patient Information
Today’s Date: ______
Whom may we thank for referring you?
______
Last Name: ______
First Name: ______
Middle Initial: ______
Date of Birth: ______(M/D/Y)
Please circle:
· Female / Male
· Married/ Single/ Child/Divorced/ Separated/Widowed/ Partnered for __years
Social Security#: ______
Address: ______
City: ______State:______
Zip Code: ______
Employer/School: ______
Occupation: ______
Employer/School Address:
______
Spouse/Parent Information
Last Name: ______
First Name: ______
Date of Birth: ______(M/D/Y)
Social Security#: ______
Employer/ School: ______
Contact Information
Home Phone #: ______
Work Phone#: ______
Cell- Phone#: ______
E-mail: ______
*We are making it more convenient for you to communicate with our practice. We will now be sending appointment reminders via email, text messages to your cell phone, pager, or PDA. Please provide us with your current information and have one less phone call to answer!
Dental Insurance Information
Insurance Company: ______
Group#: ______
Subscriber’s Name: ______
Date of Birth: ______(M/D/Y)
Social Security#: ______
Is the patient covered by additional dental insurance? YES / NO
Assignment and Release
I authorize Abel, Phan & Associates D.D.S., PLLC / Loudoun Dental Arts to file claims for services rendered to me by Abel, Phan & Associates D.D.S, PLLC / Loudoun Dental Arts. If payment is not made to Abel, Phan & Associates D.D.S., PLLC / Loudoun Dental Arts for any reason, I understand and agree that I am responsible for payment in full for services that I have received from Abel, Phan & Associates D.D.S, PLLC / Loudoun Dental Arts. Any unpaid balances will be charged at the rate of 18 %( compounded monthly) and that I will be responsible for any attorney fees in the amount of 33 1/3% for any account turned over to an attorney for collection. I understand and agree that I am ultimately responsible for checking with my insurance company regarding benefits, and failure to do so may result in a lesser payment or no payment at all. I further authorize Abel, Phan & Associates, D.D.S, PLLC / Loudoun Dental Arts to release any information, including medical information for this or any related claims to any insurance company or reimbursing agency in order to determine benefits to which I am entitled.
I hereby authorize payment to be made directly to Abel, Phan & Associates, D.D.S., PLLC / Loudoun Dental Arts realizing that I am responsible to pay any deductibles, co pays, or non-covered services as determined by my insurance company.
______
(Signature of patient/parent/guardian)
______
(Print Name of Patient/parent/guardian)
(Date)______(M/D/Y)
Medical History
For the following questions, circle yes or no whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.
1) Are you in good health? YES / NO
2) Has there been any change in your general health within the past year? YES / NO
· Date of your last physical examination: ______
· Name and address of my physician: ______
______
3) Are you under the care of a physician? YES/ NO
· If so, what is the condition being treated? ______
4) Have you had any serious illness, operations, or been hospitalized in the past 5 years? YES/ NO
· If so, what was the illness or problem? ______
5) Are you taking any medicine(s) including non-prescription medicine? YES/ NO
· If so what medicine(s) are you taking? ______
______
6) Do you have or had any of the following diseases or problems
AIDS/HIV / YES / NO / Kidney Trouble/Disease / YES / NOAnemia / YES / NO / Low blood pressure / YES / NO
Arthritis/Rheumatism / YES / NO / Mental health problems / YES / NO
Artificial Heart Valves / YES / NO / Mitral Valve Prolapse / YES / NO
Artificial Joints / YES / NO / Pacemaker / YES / NO
Asthma or Hay fever / YES / NO / Rheumatic Fever / YES / NO
Cancer/Chemotherapy/Radiation / YES / NO / Scarlet Fever / YES / NO
Cardiovascular Disease / YES / NO / Sexually Transmitted Disease / YES / NO
Cough, persistent or bloody / YES / NO / Sinus Trouble / YES / NO
Diabetes / YES / NO / Stomach Ulcer/Hyperacidity / YES / NO
Emphysema/Respiratory Problems / YES / NO / Stroke / YES / NO
Epilepsy/ Neurological Disease / YES / NO / Swollen Feet/Ankles/Neck Glands / YES / NO
Fainting spells/seizures / YES / NO / Thyroid Problems / YES / NO
Glaucoma / YES / NO / Tuberculosis / YES / NO
Heart Murmur / YES / NO / Tumor/Growth Treatment / YES / NO
Hepatitis/Jaundice/liver disease / YES / NO / Venereal Disease / YES / NO
High blood pressure / YES / NO / Weight loss (recent) / YES / NO
7) Have you ever experienced abnormally bleeding with extractions or surgery? Y/N
8) Have you ever required a blood transfusion? Y/N
9) Are you allergic or have you had a reaction to:
Local anesthetics / YES / NO / Penicillin/antibiotics / YES / NOSulfa Drugs / YES / NO / Barbiturates/Sedatives/Sleeping Pills / YES / NO
Aspirin / YES / NO / Iodine / YES / NO
Codeine or other / YES / NO / Narcotics / YES / NO
Latex / YES / NO
10) Have you had any serious trouble associated with any previous dental treatment? Y/ N
· If so, please explain: ______
11) Do you have any disease, condition, or problem not listed above that you think I should know about? Y/ N
· If so, please explain: ______
12) Are you wearing contact lenses? Y/ N
13) Are you wearing removable dental appliances? Y/ N
Women:
· Are you pregnant? Y/N
· Are you nursing? Y/N
· Are you taking birth control pills? Y/N
Chief dental Complaint:
______
______
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth about have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
______
(Signature of Patient/Parent/Guardian)
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For completion by the dentist
Comments on patient interview concerning medical history:
______
Date: ______Signature of Dentist: ______