Thomas E. Schmidt, D.D.S. and Jay B. Lindsay, D.D.S.
PATIENT & MEDICAL INFORMATION UPDATE
Name ______
LastFirstM. I. Nickname
At present are you: _____ Single _____Married _____Divorced _____Widowed _____Separated
Address ______City______State ______Zip ______
Home Telephone (_____) ______Work Telephone (_____) ______Cell (_____)______
Social Security Number ______-_____-______Birth date ______Age ______
Email Address______
Preferred way to be contacted about your appointments? home # _____ voice mail/text cell #____ work#____ email______
If employed, Name of Employer ______Employer’s Address ______
City ______State ______Zip ______
Physician’s Name ______City/State/Zip ______
If you have Dental Insurance, please complete the following:
Dental Insurance Company ______Group/Policy # ______
Address ______City______State ______Zip ______
Telephone Number (_____) ______Name of Insured (If different from above) ______
In case of an Emergency, person to notify: ______Relationship to patient:______
Home Telephone (_____) ______Work Telephone (_____) ______Cell (_____) ______
HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES, MEDICAL PROBLEMS, or MEDICATIONS?
YES NO YES NO
...... ...... Abnormal Bleeding/ Hemophilia ...... ...... Diabetes
...... ...... Allergies to Anesthetics ...... ...... Heart Problems / Pacemaker
...... ...... Allergies to Medicines, Latex, Metals ...... ...... Heart Valve Damage / Heart Murmur
...... ...... Artificial Heart Valves...... ...... Hepatitis / Liver Problems
...... ...... Artificial Joints / Joint Replacements...... ...... High / Low Blood Pressure
...... ...... Asthma/ Emphysema/ Inhaler ...... ...... HIV / AIDS
...... ...... Bisposphonates, oral(Fosamax, Boniva, Actonel) ...... ...... Immunocompromising conditions
...... ...... Bisposphonates,IV (Reclast, Zometa, Aredia) ...... ...... Kidney Problems
...... ...... Blood Disease/Leukemia ...... ...... Psychiatric Problems
...... ...... Cancer ...... ...... Sinus Problems
...... ...... Chemical Dependency ...... ...... Steroids
...... ...... Chemotherapy / Radiation Treatment ...... ...... Stomach Ulcers
...... ...... Congenital Heart Defect ...... ...... Stroke
...... ...... Coumadin, Warfarin...... ...... Tuberculosis
...... ...... Other ______
If “YES” to any response above, please explain. ______
Medications: ______
______
Changes to your health within the last few months: ______
Women: Do you think you might be pregnant? _____YES_____NO
I understand that it is my responsibility to inform this office of any change in my medical status. The above information is accurate and complete to the best of my knowledge. I will not hold the dentist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form.
Payment is due in full at the time of treatment. We accept cash, checks, and the following: VISA, MasterCard, Discover, American Express and Care Credit (an alternative payment plan). We will discuss other payment arrangements with you if these options are not available to you. As a courtesy, we will process your dental insurance claim, but request that you pay the estimated portion when services are rendered. Accounts not paid at time of service are subject to a billing charge and/or finance charge. The finance charge will be calculated at 1 ½ % per month.
I understand the medical status information and payment agreement as stated above.
Signature ______Date ______