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The benefits of a happy healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.
Please fill out this form completely.
The better we communicate, the better we care for you.
Today's Date: | Email Address: | ||
Name: | I prefer to be called: | Male | Female |
Birth date: | Age: | SS#: | |
Home Address: | Single | Married | Divorced/Separated | Widowed |
Home. # | Pager/Other # | ||
Wk. # (incl. Ext.) | DL # |
Employer: | Employer's Address: |
How long there? | Occupation: |
When and where are the best times to reach you? | Who may we thank for referring you? |
Other family members seen by us: | Previous/Present Dentist: |
Last visit date: |
His/Her Name: | |
Employer: | |
Wk # (incl. ext): | SS #: |
Birth date: | Driver's License #: |
Person Responsible for Account: | |
Wk # (incl. ext): | Home #: |
Billing Address: | |
Relation: | SS #: |
Employer: | DL #: |
Primary | |
Dental Coverage: Yes No | Medical Coverage: Yes No |
Insurance Co. Name: | |
Insurance Co. Address: | |
Insurance Co. Phone #: | |
Group #(Plan, Local or Policy #): | |
Insured's Name: | Relation: | Insured's Birth date: | Insured's SS #: |
Insured's Employer: | |
Secondary | |
Dental Coverage: Yes No | Medical Coverage: Yes No |
Insurance Co. Name: | |
Insurance Co. Address: | |
Insurance Co. Phone #: | |
Group #(Plan, Local or Policy #): | |
Insured's Name: | Relation: | Insured's Birth date: | Insured's SS #: |
Insured's Employer: | |
In the event of an emergency, is there someone who lives near you that we could contact? | His/Her name: | Relation: | Work #: | Home #: |
Do you have a personal Physician? Yes or No | |
Physician's Name: | |
Your current physical health is: Good or Fair or Poor | |
Are you currently under the care of a Physician? Yes or No | |
Please explain: | |
Are you taking any prescription drugs? Yes or No | |
Please list each one: | |
Do you smoke or use tobacco in any other form? Yes or No | |
For Women: Are you taking birth control pills? Yes or No | Are you pregnant? Yes or No | Week #: |
Are you nursing? Yes or No |
Have you ever had any of the following diseases or medical problems? | Y N Abnormal Bleeding | Y N Hepatitis | Y N Alcohol/Drug Abuse | Y N Herpes/Fever Blisters | Y N Anemia | Y N High Blood Pressure | Y N Arthritis | Y N HIV or AIDS | Y N Artificial Bones/Joints/Valves | Y N Hospitalized for any reason | Y N Asthma | Y N Kidney Problems | Y N Blood Transfusion | Y N Liver Disease | Y N Cancer/Chemotherapy | Y N Low Blood Pressure | Y N Colitis | Y N Mitral Valve Prolapse | Y N Congenital Heart Disease | Y N Pacemaker | Y N Diabetes | Y N Psychiatric Problems | Y N Difficulty Breathing | Y N Radiation Treatment | Y N Emphysema | Y N Rheumatic/Scarlet Fever | Y N Epilepsy | Y N Seizures | Y N Fainting Spells | Y N Shingles | Y N Frequent Headaches | Y N Sickle Cell Disease/Traits | Y N Glaucoma | Y N Sinus Problems | Y N Hay Fever | Y N Stroke | Y N Heart Attack | Y N Thyroid Problems | Y N Heart Murmur | Y N Tuberculosis/TB | Y N Heart Surgery | Y N Ulcers | Y N Hemophiliac | Y N Venereal Disease | Please list any serious medical conditions that you have ever had: |
Are you allergic to any of the following? | Y N Aspirin | Y N Codeine | Y N Dental Anesthetics | Y N Erythromycin | Y N Jewelry | Y N Latex | Y N Metals | Y N Penicillin | Y N Tetracycline | Please list any other materials that you are allergic to: |
Why have you come to the dentist today? | |
Do you require antibiotics before dental treatment? Yes or No | |
Are you currently in pain? Yes or No | |
Have you ever had a serious/difficult problem associated with any previous dental work? Yes or No |
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Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes or No | |
Your current dental health is: Good or Fair or Poor | |
Do you like your smile? Yes or No | |
Would you like whiter teeth? Yes or No | Fresher breath? Yes or No |
Do your gums ever bleed? Yes or No | |
How many times a week do you floss? | a day do you brush? |
Type of bristles? Soft or Medium or Hard | |
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize my dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. |
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Payment is due in full at the time of the treatment unless prior arrangements have been approved. |
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover.
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Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. |
*OFFICE USE ONLY*OFFICE USE ONLY*OFFICE USE ONLY* | ||
I verbally reviewed this medical Dental information above with the patient named herein. initials_____ date______ |
Doctor's Comments:________________________________________________________________ __________________________________________________________________________________ |
1. Date:________ | Comments:_______________________________ | Signature:_______________ | 2. Date:________ | Comments:_______________________________ | Signature:_______________ | 3. Date:________ | Comments:_______________________________ | Signature:_______________ |
HOME ||
CREDENTIALS ||
SERVICES ||
PROCEDURES
INSURANCE ||
STAFF ||
POLICIES ||
LOCATION ||
CONTACT