Patient Form

    Please fill out the form below.

    Questions with an asterisk are required. If a question does not apply, please enter N/A

    Medical History

    Today's Date * :

    Patient Name:

    First Name * :

    Middle Name:

    Last Name * :

    What do you prefer to be called?

    Patient Address * :

    City * :

    State * :

    Zip * :

    Home Phone * :

    Business Phone:

    Cell Phone * :

    Email * :

    Birth Date * :

    Height:

    Weight:

    Employer Name :

    Employer Address:

    Employer City:

    Employer State:

    Employer Zip:

    Occupation:

    Employer Phone :

    Emergency Contact Name * :

    Emergency Contact Phone * :

    Marital Status

    MinorSingleMarriedDivorcedSeparatedWidowed

    Spouse Name:

    General Physician Name * :

    General Physician Phone * :

    General Physician Address:

    General Physician City:

    General Physician State:

    General Physician Zip:

    Last Physical Date * :

    Cardiologist Name:

    Cardiologist Phone:

    Cardiologist Address:

    Cardiologist City:

    Cardiologist State:

    Cardiologist Zip:

    Pertinent Specialist Name:

    Pertinent Specialist Phone:

    Pertinent Specialist Address:

    Pertinent Specialist City:

    Pertinent Specialist State:

    Pertinent Specialist Zip:

    Referred by/How did you find our office * :

    NOTE: These questions are for your benefit. This confidential information will assist us in your diagnosis and treatment.

    Check any of the following which apply to you

    Heart TroubleHeart SurgeryHeart Valve ProsthesesCongenital Heart ProblemsHeart MurmurRheumatic Fever/Scarlet FeverStrokeHigh Blood PressureGlaucomaStomach Ulcers

    HemophiliaAnemiaLeukemiaSickle Cell DiseaseKidney DiseaseDiabetesThyroid DiseaseJaundiceLiver DiseaseHepatitis

    Hives/ShinglesSinus TroubleAsthmaEmphysemaTuberculosisPersistent CoughEpilepsyFainting/DizzinessHerpes/Cold SoresSexually Transmitted Disease

    AIDS/HIVJoint Replacement ProsthesisArthritisCancerChemotherapyCortisone MedicineBlood TransfusionPsychiatric CareDrug DependenceChild Births

    List all medications or drugs (including aspirin, vitamins, hormones, antacids, steroids or birth control pills) which you are presently taking or have taken in the last six months (including dosage and frequency) * :

    Has there been any change in your general health in the last year?

    If yes, explain:

    Have you been hospitalized, seriously ill, injured, or under a doctor's care during the past two years?

    If yes, explain:

    Are you allergic or have you experienced an unusual reaction to any drugs?

    If yes, list medications:

    Have you experienced excessive bleeding that required special treatment?

    If yes, explain:

    Are you or have you ever been addicted to any medications?

    If yes, list medications:

    Is there a history of any of the following in your immediate family?

    DiabetesHeart DiseasePeriodontal Disease

    Have you ever been treated for a growth or tumor in any part of your body?

    If yes, explain:

    Do you smoke?

    CigarettesCigarsPipes

    How long have you been smoking?

    Do you get headaches?

    MigrainesFrequent headachesWake up with headaches

    If so, what is the duration?

    Have you been diagnosed with sleep apnea?

    Do you wear a CPAP or any breathing device at night?

    Does your mouth or your eyes feel dry?

    Have you ever had Botox or dermal fillers?

    WOMEN: are you pregnant or nursing?

    Anticipating Pregnancy?

    Experiencing menopausal symptoms?

    List any disease, condition or problem (not listed) that you feel we should know about:

    Dental Health History

    Check any of the following which you may have had or experienced:

    Injury to Face or JawSlow Healing Mouth SoresFever BlistersMouth UlcersSwollen GumsBleeding Gums

    Sensitivity to HotSensitivity to ColdMouth OdorBad Taste in MouthLoose TeethChange in Bite

    Aches in Jaw JointsTired Jaw or Sore MusclesClicking/Popping in JawJaw Locking-open/closedRoot Canal TherapyOrthodontic Therapy

    If you are currently experiencing pain in your mouth, where is it located?

    How do you feel about keeping your teeth for the rest of your life?

    If you’re not happy with the appearance of your teeth, what would you change?

    Select which of the following you use on a daily basis:

    Manual Toothbrush

    Electric Toothbrush

    If yes, write brand name:

    Mouth Rinse

    Fluoride Rinse

    Floss

    Proxabrush

    Other

    Have you had previous periodontal (gum) treatment?

    If yes, what procedure was performed?

    When was it performed?

    Have you had oral surgery?

    If yes, what procedure was performed?

    When was it performed?

    Have you had crown and/or bridge work?

    If yes, what procedure was performed?

    When was it performed?

    Have you ever had orthodontic therapy (braces)?

    If yes, when?

    Have you ever worn a bite guard, bite plane or night guard?

    If yes, do you currently wear it?

    Have you noticed any change in the position of your teeth?

    If yes, explain:

    Do you have any difficulty chewing?

    If yes, explain:

    Is it difficult to open your mouth wide?

    If yes, explain:

    Are you worried about receiving dental treatment?

    If yes, what is your main concern?

    When did you last have your teeth cleaned:

    Date of last dental x-rays:

    When was your last dental treatment (ex: crown, filling, etc)?

    What procedure was performed?

    Previous Dentist Name:

    Phone:

    How long were you his/her patient?

    Pattern of Dental Care:

    ConsistentSporadicInfrequent

    Other concerns:

    Insurance Information

    Person responsible for the account (if different than above)

    Name :

    Relationship:

    Address:

    City:

    State:

    Zip:

    Home Phone:

    Date of Birth:

    Insured Employer Name:

    I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid for by my insurance company.

    Primary Dental Insurance

    Dental Insurance Company:

    Address :

    City:

    State:

    Zip:

    Phone:

    Group Number:

    Member ID Number:

    Secondary Insurance

    Dental Insurance Company:

    Address :

    City:

    State:

    Zip:

    Phone:

    Group Number:

    Member ID Number:

    Financial Agreement

    Thank you for choosing our office. We are committed to providing you with the best possible care. If you have any questions regarding fees for treatments, please feel free to discuss them with us. We will make every effort to avoid misunderstandings and preserve our relationship.

    Payment for services is due at the time treatment is rendered. If you have dental insurance, we are happy to help you receive maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policies. We will process your insurance claims for reimbursement as well as accept insurance assignment from insurances in which we are Participating Providers. Our office is provided with General Benefit information from your insurance, which is not specific and does not guarantee exact amounts to be paid by your insurance carrier. If for any reason your insurance denies the claim, you will be responsible for the balance.

    Your deductible, if any, and your estimated co-payment are collected at the time of service. We cannot guarantee exact amounts to be paid by your insurance carrier. If there is any remaining balance after your insurance has processed your claim, the balance is your responsibility.

    Missed and broken appointments waste valuable resources and raise fees for everyone. In an effort to reduce this expensive waste there will be a charge of $75.00 for broken or missed appointments. A broken appointment is classified as the failure to appear for an appointment where the cancellation was not made 48 hours in advance, or lateness that results in an inability to complete scheduled treatment.

    Returned checks due to insufficient funds or closed accounts will have a $35 charge.

    If your account must be placed in the hands of a third party for collections, your account will be charged 1/3 of the total balance for the collection fee.

    If you have any questions about the above information or any uncertainty regarding your insurance coverage, please do not hesitate to ask us.

     

    I have read the above conditions of treatment and payment and agree to their content.

    Signature of guarantor of payment/responsible party:

    Signature * :

    Date * :

    Relationship to Patient (or enter Self) * :

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