Cheshire Dental Associates Patient Name Spouse Name Address City, State, Zip Cell Phone Email Patient Soc. Sec # Spouse Soc. Sec # Date of Birth Home Phone Work Phone Referred By How should we contact you? Email Cell Phone Home Phone Work Phone Your Primary Insurance Company Name Primary Insurance Company s Address Effective Date Phone City State Zip Policy Holder s ID number Group Plan Number Employer s Name Your Secondary Insurance Company s Name Primary Insurance Company s Address Effective Date Phone City State Zip Policy Holder s ID Number Group Plan Number Employer s Name Name of Insured Date of Birth Financial Policy 1. Payment is expected at the time the work is done. Although you may have insurance, your Patient Portion must be paid at the time of visit. 2. Financial agreements must be made if payment in full at each visit is not possible. Finance charge of 1.5% (18% annually) will be added monthly after 60 days to any unpaid balance. In the event of default, the patient and/or guardian are liable for all collection costs and reasonable attorney fees. 3. We accept Cash, Check, Credit Cards and Care Credit (Signature of Patient and/or Guardian)
Dental and Oral Health Information 1 Pa tient s name: Date: Plea se describe an y spe cific dental problem or discomfort you are having at this t ime: How long has it been prese nt? If you have had any of the following dental c are please list the dentists and approx imate dates: Periodontal (gum) tr eatment or surgery Braces or any type of ortho dontic treatment: Dental implants : Any other type of oral surgery: Do you have / have you had / have you noticed any of t he following signs or symptom s in your head, neck, or mout h? (Please check Yes or No for each question) Teeth that are sensitive to: A clicking, snapping or d ifficulty when chewing Hot, cold, sweets, or biting press ure Difficulty opening or moving the jaws An unpleasant taste or pers istent bad breath Difficulty speaking or changes in your voice Does food catch between your teeth Difficulty moving your tongue or tongue tied Do your gums bleed whe n brus hing Loose or separ ating teeth Red, swollen, tender, b leeding, or sore gums Changes in the way your teeth f it toge ther Gums that have pulled a way from the teeth A color change of the t issues in your mouth Pus between the teeth and gums Pain, tender ness, numbness, or earac hes Avoid any area when brus hing or chewing Any lumps, swelling or swollen glands You clench or grind your teeth Sore s, ulcers, or rough spots in your mouth Your Dental Health: How do you rate your overall dent al health? Good Fair Poor How many t imes a day do you brush your teeth? How many t imes a week do you f loss your teeth? Do you use any of t he follow ing? (Please check Yes or No for each question) Mechanical (electric) toothbru sh If Yes, what type or brand? Flossing aids (floss holders, thre ader s, etc.) Oral irrigating device (W aterpik) Fluoride treatments or supplements a t home. If Yes, which ones: Mouthwashes or oral rinses. If Yes, what brand? Do you have any miss ing teeth that have not been replaced? Why have you not had them replaced? Do you wear any remova ble dental appliances? If Yes, what type and for how long? Have you ever had your teet h whitened or bleached? Wou ld you like to have your teeth whitened or bleached? How do you feel about t he appearance of your smile and what w ould you change if you could? Are you concerned about the finances required to return your mouth to excellent health? Are you frustr ated because you always need som ething treat ed or repaired when you visit a dentist? Do you feel you will eventually we ar art ificial dentur es? Have you ever had any complications from an extract ion or dental treatm ent? If Yes, please expla in: Have you ever had any other dent al conditions, major t raum a or injury to your head, neck, or mouth? If Yes, please speci fy: If you are a new patient t o this practice: Date of last denta l v isit Dentist s name City & State Copyright LED Dental, Inc. (05-23-06) Reviewed By:
Health Information and History Today s Date: Patient s Name: Date of Birth: If you are completing this form for another person: Your name: Phone: Relationship: 1 Emergency Contact: (If not listed above) Name: Phone: Relationship: Primary Physician: Phone: City & State: Date of last physical examination: Date of last blood test/work up: Other Physicians & Specialists Name: Specialty: Phone: City & State: Name: Specialty: Phone: City & State: 1. With in the last 3 years, have you been hospitalized or had surgery? If Yes, please give reasons and dates: 2. Have you ever been instructed to take ANY medications or take ANY special precautions before any dental appointments*? If Yes, please explain: 3. Are you taking ANY drugs, medications, or treatments at this time? (If you brought a complete written list with you, give that to the receptionist instead) Prescribed: Over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medication, sleeping aids, etc): Vitamins, natural or herbal preparations and/or dietary supplements: Are you having or have you ever had radiation or chemotherapy treatments*? If Yes, for how long? Name of facility performing the treatment : 4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)? 5. Are you allergic to or have you ever experienced an unusual reaction to: Latex Metals or jewelry Dental anesthesia (local) Fluoride Nitrous oxide (laughing gas) General anesthesia 6. Are you allergic to or have you ever had any reaction to any of the following drugs? Penicillin (or related drugs) Tranquilizers (Valium) Tetra cycline Codeine Aspirin / Ibuprofen (Advil, Motrin, Nuprin) Keflex (Cephalexin) Sulfa drugs Iodine NSAID (Celebrex, Vioxx, Anaprox) Clindamycin (Cleocin) Erythromycin 7. Have you had an allergic reaction or unusual response to ANY other medications, drugs, pills, or treatments? If Yes, please list : Continued on next page Reviewed By: Copyright LED Dental Inc. (04-30-07)
Health Information and History (continued) Patient s Name: 2 8. Do you have, or have you ever had, any of the following? (Please check Yes or No for each question) Congenital heart defects Angina or chest pains Atherosclerosis Congestive heart failure Coronary artery disease Heart surgery If Yes, type & date Heart attack If Yes, date Rheumatic heart disease / rheumatic fever Infective Endocarditis* Heart valve(s) damage / Mitral valve prolapse Artificial heart valve Pacemaker Stroke or CVA High blood pressure Low blood pressure Anemia Hemophilia or bleeding disorder Excessive bleeding from any cut or incident Diabetes or blood sugar problems Any artificial joint, joint surgery, or prosthesis If Yes, what join t or area: When was operation done: Hepatitis, jaundice, or other liver problems Any form of cancer An organ transplant Asthma Hay fever, skin or food allergies or allergies in general Sinus problems Tuberculosis, emphysema or lung disorder Skin problems A sore or wound that bleeds easily or does not heal A thyroid problem or disease Arthritis Glaucoma or any eye diseases Epilepsy or other seizure disorder Any kidney problems Ulcers, acid reflux, or stomach problems A compromised immune system (Lupus, HIV, AIDS, radiation immune problem, etc.) An active sexually transmitted disease (STD) Any mental health issues Been treated for any psychiatric condition Women Only: Are you pregnant If Yes, what is your due date: Do you think you might be pregnant Are you presently nursing Are you using birth control medication Are you taking hormone replacement therapy 9. Do you have any other conditions, diseases, or medical problems, or is there ANY other information that you would like us to know about, or that we should be made aware of? If Yes, please explain: CONSENT To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient s health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice. I understand there are no guarantees or warranties in health or dental care. Signature Date (Parent or guardian, if patient is a minor) Reviewed By: Copyright LED Dental Inc. (04-30-07)
CHESHIRE DENTAL ASSOCIATES, P.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse to Sign this Acknowledgement* I, have received a copy of this office s Notice of Privacy Practices. Please Print Name Signature Date MISSED APPOINTMENTS Any missed appointment that was not cancelled with CDA personnel, at least 24 hours in advance, a $25.00 fee will be charged to your account. Subsequent missed appointments will be subject to additional fees. Signature Date