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Transcription:

Welcme t A very warm welcme t yu! The entire team wuld like t thank yu fr selecting ur ffice t care fr yur dental needs. We are a family-riented dental practice lcated n the suthwest crner f Furteen Mile and Middlebelt Rad in Farmingtn Hills. Mst dental insurance plans are prcessed by us fr yur cnvenience. We ffer prmpt care fr all emergencies. ur ffice hurs (listed n the back) are by appintment, (248) 626-772 Generally, the first visit will include a cmprehensive examinatin and necessary x-rays fr prper diagnsis, fllwed by a cnsultatin f yur dental needs, (unless yu have a particular prblem requiring immediate attentin). Ireatment csts will be discussed and. financial arrangements can be made., ur gal is t prvide each patient with the highest qualify care ni a gentle, efficient and pleasant manner. We ah aid and strngly encurage preventin f future dental prblems... quality dental health care! Marc L. Dwskin, D.D.S., P.C. Sctt J. wens, D.D.S. Linda M. Frtin, D.M.D., P.C. Wdbury ffice Park 32931 Middlebelt, Suite 68 Farmingtn Hills, MI 48334 www. d rd w ski n. c m Lking frward t seeing yu

Csmetic & Family Dentistry. Dwskin, MDS, P.C. Sctt I wens, $$$, P. 32931 Middlebelt Rad, Suite 68 Farmingtrt Hills, Ml 48334 (248) 626-772 Fax (248) 626-3572 PATIENT INFRMATIN Q F Date f Birth: Nearest relative nt living with yu Hw lng at this address? Resident phne: ( ) Cell phne: ( ) Email: ( ) Previus address if less than 3 years Scial Security N.: Driver's License N.: Yur emplyer: ccupatin: Business address: Business phne: ( Pager: Years with firm: May we cntact yu at wrk? Whm may we thank fr referring yu t us? Relatin t yu: Address: Resident phne: ( ) Business phne: ( Is there dental insurance f which we need t be aware? Yur dental insurance cmpany: Grup #: Spuse's dental insurance cmpany: Grup #: Name f spuse:. Date f Birth: Address (if different):. E-mail: Scial Security N.:_ Driver's License N.: Emplyer: ccupatin: Business address: Business phne: ( Years with firm: ext. Persn respnsible fr this accunt: Whm may we cntact in an emergency Credit card reference:

MEDICAL HISTRY N 1. Are yu in gd health? 2. Has there been any change in yur general health within the past year? 3. My last physical examinatin was n 4. Are yu nw under the care f a physician? a. If yes, what cnditin 5. Name f physician 1. Add ress 2. Phne( ) 6. Have yu had any serius illness r peratin? a. If yes, what was the illness r peratin and when was it? 7. D yu have r have yu ever had any f the fllwing? a. Damaged heart valves r artificial valve? b. Cngenital heart lesins? c. Rheumatic heart disease, r rheumatic fever? d. Heart murmur r mytrvalve prlapse e. Cardivascular disease (heart attack, angina, high r lw bld pressure, arterisclersis, strke)? f. D yu wear a cardiac pacemaker? g. Allergy, asthma, hay fever, r sinus truble? g1. Latex allergy h. Emphysema, tuberculsis, r ther lung prblems? i. Persistent cugh r cugh up bld? j. Diabetes? k. Hepatitis, jaundice, r ther liver disease? I. Epilepsy? m. Arthritis, inflammatry rheumatism r artificial jints? n. Ulcers r clitis?. Kidney truble? p. Neurlgical prblems? q. Glaucma r ther eye disrders? r. Mnnuclesis r mumps? s. Fever blisters r cld sres? t. Venereal disease? u. HIV/AIDS? v. Psychiatric care/emtinal prblems? w. An artificial jint? x. Pre medicated fr any cnditin? y. Lyme disease? z. Lupus? 8. Have yu ever had abnrmal bleeding assciated with previus extractins, surgery r trauma? 9. Have yu ever had a bld transfusin? 1. D yu have any bld disrder such as anemia, hemphilia? 11. Have yu ever had surgery, x-ray treatment r chemtherapy fr a tumr, grwth r any ther cnditin? 12. Are yu taking any f the fllwing? a. Antibitics rsulfa drugs b. Anticagulants (bld thinners)? c. Medicine fr high bld pressure r ther heart prblems? d. Crtisne (sterids)? e. Tranquilizers? f. Antihistamines? g. Aspirin? h. Insulin r ral medicine fr diabetes? 1. Nitrglycerin? j. ral cntraceptives (birth cntrl pills)? k. Thyrid r ther hrmnal therapy? I. Antidepressants? m. Anti-rejectin medicatins? n. ther Marc L. Dwskin, D.D.S. 32931 Middlebelt Rad, Suite 68 Farmingtn Hills, Michigan 48334 (248) 626-772 Fax (248) 626-3572

AL HmUKY (cnrd.) allergic r sensitive a. b. c. d. e. f. g. h. Lcal anesthetic? Nitrus xide? Penicillin r ther antibitics9 Barbiturates sedatives r sleeping pills? Aspirin9,. Idine9 Cdeine r ther narctics? ther N 14. D yu wear cntact lenses? 15. Wmen: Are yu pregnant? What mnth? Are yu nursing? 16. D yu smke? Packs per day? D yu use smkeless tbacc? 17. D yu drink alchl? Hw ften? 18. D yu have any disease, cnditin, r prblem nt listed abve that I shuld knw abut? 19. D yu use drugs? (Ccaine, methamphetamines, herin, etc.) This can cause an adverse reactin t lcal anesthetic. DENTAL HISTRY N 1. What is the reasn fr this appintment? 2. 3. 4. 5. 6. 7. 8. 9. 1. 11. 12. 13. 14. 15. 16. When was yur last dental visit? Name f previus dentist Why? Address Phne ( ) D yu have any fear f dental treatment9 Are yur teeth sensitive t: Heat Cld Sweets Biting Tthbrushing ther a) Are yu missing any teeth9 b) Have they ever been replaced9 c) If nt why9.. Have yu ever had any f the fllwing treatments: rthdntics (braces) Enddntics (rt canal) Peridntics (gum) cclusal Bite Adjustment (TMJ) Bite Splint Crwns (caps) Bnding ral Surgery (extractins Dentures r partial dentures Bipsy Implants Hw ften d yu brush yur teeth? a) D yu have difficulty flssing?... b) Hw ften d yu flss? D yu have bleeding gums? D yu have any unpleasant taste r dr in yur muth? Des fd get caught between yur teeth? D yu clench r grind yur teeth? D yu hear ppping r clicking nises when yu pen, clse r chew? D yu have any pain in r arund yur ears? a) D yu ever have headaches, neck aches r a sre jaw? b) Have yu ever had a head, face r neck injury? Please cntinue Marc L. Dwskin, D.D.S. 32931 Middlebelt Rad, Suite 68 Farmingtn Hills, Michigan 48334 (248) 626-772 Fax (248) 626-3572

DENTAL HISTRY (cnt'd.) 1 7. D yu have any biting r chewing habits? Fingernails Pen r pencil Cheek, tngue r lip Pipe Ice N 18. 19. 2. 21. 22. ther D yu like the appearance f yur teeth? Are yur frnt teeth straight? Are yur frnt teeth even in length? Are yur teeth all the same clr? If yu culd change yur smile, what wuld yu mst like t chanae? CNSENT: The undersigned hereby authrizes Dctr t take X-rays, study mdels, phtgraphs, r any ther diagnstic aids deemed apprpriate by Dctr t make a thrugh diagnsis f the patient's dental needs. I als authrized Dctr t perfrm any and all frms f treatment, medicatin and therapy that may be indicated in cnnectin with (name f patient) and further authrize and cnsent that Dctr chse and emply such assistance as he deems fit. I als understand the use f anesthetic agents embdies a certain risk. I Understand that respnsibility fr payment fr Dental Services prvided in this ffice fr myself r my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1 1/2% FINANCE CHARGE will be added t any balance ver 3 days. In the event f default (we) prmise t pay legal interest n the indebtedness, tgether with such cllectin csts and reasnable attrney fees as may be required t effect cllectin f this nte. Patient Date Witness Patient r Respnsible Party Relatinship t Patient. Marc L. Dwskin, D.D.S. 32931 Middlebelt Rad, Suite 68 Farmingtn Hills, Michigan 48334 (248) 626-772 Fax (248) 626-3572

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