TISTAERT DENTAL

Title______Name ______DOB______

Address______

Phone: home ______work______

Cell ______single married widowed divorced partner

SS# ______Email ______

Employer & Address ______

Insurance ______Secondary? ______

Spouse’s insurance? ______SS# ______

Emergency contact: ______

My Doctor ______Phone ______

Allergies:______Peanuts ______

Do you smoke? ______Drink______Street drugs ______Pregnant? ______

(WRITE yes or no)

Generally in good health? ______Ever take FenPhen or Redux ______

Ever had reaction to anesthetic? ______Describe______

Chronic med. Problems: Ms, Diabetes, etc. ______

Have or had hearth problems:

High blood pressure ______thyroid______medicine needed?______Bleeding easily______

Stroke______kidney______lungs (asthma, emphysema, etc)______cough______candida ______

Mono______liver(jaundice, hepatitis)______skin______muscle/joint/bone______epilepsy______

Mental______fainting______neurological______eyes______ears/hearing______sinus______

TMJ(pain, sounds, dislocated)______head injury______freq. headaches______tumors______

Radiation/chemo______infections(TB, AIDS/HIV, shingles, herpes, hepatitis, etc)______

Venereal Diseases______Cold sores______Artificial parts (joints, valves, pacemaker)______

Add anything else, or explain ______

Please initial______Date______

TISTAERT DENTAL

PRINT NAME______

Until the patient is examined & dental needs know; it is not possible to know what financial arrangements will be best. In this evaluations your will be receiving the best advice & assessment of Dr. Tistaert, who has many years of personal experience as well as gleaned from his father’s and grandfather’s dental experience. So for his expertise theses services are to be paid for at the time rendered. Afterwards we will agree upon treatment and the estimate for those services; but as any work proceeds unexpected findings & adjustments can arise. Fees for all emergency services are payable at the time of the visit. I give my consent for Dr. Tistaert, or his associates, to give my insurance company any information required about my dental condition or treatment needed to determine benefits for up to 5 years from this date. I understand I am responsible for dental services regardless of my insurance. I understand & have had thechange to ask any questions about this.

Date______Patient______

D.D.S. ______

CURRENT MEDS: (i.e. blood thinners, aspirin, steroids, antihistamines, tranquilizers, diabetic drugs, hearth/blood pressure, nitro, thyroid, herbal or natural remedies)

List ALL MEDS: ______

List ALL ALLERGIES:______

List Surgeries:______

Are you interested in cosmetic dentistry, whitening or other smile improvements?______

Any other dental questions/concerns? ______

CONSENT FOR TREATMENT: I hereby grant permission to Dr. Tistaert or his associate for my dental care, to administer such dental anestheticsas needed for dental work and to perform such operations or dental procedures as deemed necessary or advisable in diagnosis & treatment of this myself, or my minor children.

FINANCIAL: fees to be paid in 30 days, older accounts will have a fee of 1.5% (1 ½ %) will be assessed each month or 18% per year.

I have received the Dental Materials Face Sheet /law(initials)______Date______

Signed ______Date______