PATIENT INFORMATION Name: Birthdate: Street Address: City: State: Zip: Hme Ph: Cell Ph: Email: SSN#: Sex (circle) M F Emplyer Name & Phne #: PARENT/GUARDIAN INFORMATION (IF UNDER THE AGE OF 18) Name: Relatinship t Patient: Address: City: State: Zip: Hme Ph: Cell Ph: Email: Emplyer Name and Phne #: PRIMARY INSURANCE INFORMATION (If n insurance, skip t fllwing page) Subscriber Name: Relatinship t Patient: Date f Birth: SS#: Emplyer Name & Address: Insurance Cmpany: ID#: Grup #: Insurance Phne #:
SECONDARY INSURANCE INFORMATION Subscriber Name: Relatinship t Patient: Date Of Birth: SSN#: Emplyer Name & Address: Insurance Cmpany: ID#: Grup #: Insurance Phne #: OTHER Whm may we thank fr referring yu t ur ffice? ASSIGNMENT AND RELEASE I certify that I and/r my dependant(s) have insurance cverage with Name f Insurance Cmpany and assign directly t TruBlu Dentistry all insurance benefits, if any, therwise payable t me fr services rendered. I understand that I am financially respnsible fr all chargeswhether r nt paid by my insurance. I authrize the use f my signature t all insurance infrmatin. The abve named cmpany and its assciates r agents may use my health infrmatin and may disclse such infrmatin t the abve named insurance cmpany(ies) and their agents fr the purpse f btaining payment fr services and determining insurace benefits r the benefits payable fr related services. Sign: (Patient r Legal Guardianif under 18) Print Name: Relatinship t Patient: Date:
MEDICAL HISTORY FORM Patient Name Birth Date: DENTAL HISTORY What is the reasn fr tday s visit? When was yur last visit t a dentist? Hw d yu feel abut the appearance f yur teeth? D yu have r have yu had any f the fllwing? (Please check all that apply t yu) Anemia Lw Bld Pressure Tbacc Habit Arthritis Rheumatism Artificial heart valves Artificial jints Asthma Chrnic/persistent cugh Cughup Bld Diabetes Epilepsy/seizures Fainting Glaucma/eye disrders Migraine Headaches Heart Murmur Heart Disease (describe) Hemphillia Hepatitis/liver disease/jaundice High Bld Pressure HIV AIDS Kidney Disease Mitral Value Prlapse Malignant Tumr/Cyst Nervus Disrders Pacemaker Psychiatric Care Radiatin Treatment Respiratry Disease Rheumatic Fever/Rheumatic heart disease Shrtness f Breath Skin Rash Strke Cngestive Heart Failure Thyrid Disease Tuberculsis Ulcer/Digestive Disrders Venereal Disease Sinus prblems Autimmune Disease Back prblems Bld Disease Abnrmal bleeding Cancer Chemical Dependency Chemtherapy Circulatry Prblems Crtisne Treatments/Sterids Allergies t Penicillin Pregnant Date f last Physical Exam: (Wmen) Nursing? Y / N Taking Birth Cntrl? Y / N D yu cnsider yurself t be in gd health? Allergies/Reactins t medicatins? Are yu presently under a Physicians care? Y / N Explain: Physicians Name & Phne #: Please list all medicatins yu are curently taking as well as ver-the-cunter medicatins, herbal remedies, vitamins, hmepathic remedies:. Patient Signature: Date:
INFORMED CONSENT OF TREATMENT FOR ADULT PATIENTS This frm is t btain yur cnsent fr yur dental treatment r ral surgery prcedures. Please read this frm very carefully and ask us abut anything that yu d nt understand. Yur dentist r the staff will be pleased t explain it. Thank yu. A. Belw is a list f dental prcedures that may be perfrmed n yu; but this list is nt a cmprehensive list f all pssible dental prcedures. A treatment plan will be made fr yu and presented t yu after the initial examinatin. Prir t each appintment the specific treatment that will be perfrmed n yu that day will be explained t yu. 1. Diagnstic Prcedures: Examinatin, radigraphs (x-rays) f the teeth & jaws, cnsultatin, phtgraphs, dental cast. 2. Dental Cleaning: Remval f sft and hard depsits n teeth, and teeth plishing with special tthpaste. This may entail a mre extensive prcedure called scaling and rt planing r deep cleaning depending n the health f yur teeth and gums, yur dentist will infrm yu which kind f cleaning yu need. 3. Fluride Treatment: A slutin f fluride is placed n the teeth after cleaning. Fluride hardens the surface f teeth and helps resist tth decay. 4. Dental Sealants: Plastic sealants are applied t the grves f the chewing surface newly erupted permanent mlar teeth t help resist tth decay. 5. Lcal Anesthesia Injectin: Numbing medicine carefully used t numb the teeth and surrunding areas prir t certain dental prcedures such as tth remval r dental fillings. 6. Dental Rubber Dam: A sheet f latex rubber used t carefully islate the teeth that need dental treatment. 7. Dental Fillings/crwns: Depending n the size f the tth decay, and lcatin f tth in the muth, the fllwing may be dne. Frnt teeth: white filling/crwn. Back teeth r canine teeth: silver amalgam fillings r tth clred cmpsite fillings. 8. Pulp (tth nerve) Treatment: A prcedure t save teeth that wuld therwise be lst because f a deep cavity that has affected the tth nerve. Yur dctr may have yu sign a mre specific cnsent frm fr this prcedure. 9. Extractin: Teeth may be remved because f infectin, injury, rthdntic reasns (teeth crwding), r if they are diseased and cannt be saved by any dental prcedures. Yur dentist may ask yu t sign a mre specific cnsent frm fr this prcedure. Cap r Crwn: When teeth are badly brken dwn, at risk fr fracture, r fllwing a rt canal prcedure, yu may need a crwn r cap fr yur tth. Yur dentist will explain if this is needed fr yu and what this will entail. Yur dentist may als ask yu t sign a mre specific cnsent frm fr this prcedure. The nature and purpse f the treatment and prcedures have been explained t me in general terms by the dental staff at TruBlu Dentistry. Alternate prcedures r methds f treatment if any, have been explained t me. I have als had the advantages, disadvantages, risks, cnsequences, and prbable effectiveness f each explained t me, as well as the prgnsis if n treatment is prvided. I am advised that thugh the results f the treatment are expected t be gd, the pssibility and nature f cmplicatins cannt be accurately anticipated fr everyne. Therefre, there can be n guarantee as expressed r implied either f the result f the treatment r f the cure. Risks and Cmplicatins: Althugh their ccurrence is nt frequent, sme risks and cmplicatins are knwn t be assciated with dental r ral surgery prcedures. Pssible cmplicatins include the risk f numbness, infectin, swelling, prlnged bleeding, disclratin f tissues, vmiting, allergic reactins, swallwing r asperatin f dental materials, an extracted tth r gauze packing, injury t the tngue and lips, damage t the pssible lss f existing teeth and r fillings, injury t nerves near the treatment site, and fracture f a tth rt which may require additinal surgery fr its remval. Fr patients with certain heart diseases, the risk f Infective Endcarditis (heart infectin) fllwing certain dental prcedures exists. Therefre, antibitics will be prescribed befre the treatment, t minimize the risk. I further understand and accept that cmplicatins may require additinal medical, dental, r surgical treatment that may require hspitalizatin. We prescribe antibitics prir t appintments in accrdance with the American Heart Assciatin guidelines. I hereby acknwledge that I have read and understand this cnsent frm. I have als been given the pprtunity t ask any questins that I might have abut the prcedures and have been answered in a satisfactry manner. I understand that I have
the right t be prvided with answers t questins, which may arise during my dental treatment. I als understand that I am free t withdraw my cnsent t treatment at any time. This cnsent shall remain in effect until I chse t terminate it. D yu have any bjectins? Yes N If yes, please explain. By signing this cnsent frm, I authrize and direct the dentist at TruBlu Dentistry assisted by the dental staff f his/her chice, t perfrm the dental treatment r ral surgery prcedures explained herein. Tday s Date: Patient s Name: Date f Birth: Patient s Signature: