Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are you: a Minor Single Married Separated Divorced Widowed Patient s or parent s employer: Occupation: Business address: Spouse s name: Employer: Spouse s business address: Spouse s work number: In the event of an emergency, who should we contact (not living with you)? Relationship: Home phone: Work phone: Whom may we thank for referring you? RESPONSIBLE PARTY Person responsible for this account: Relationship: Address: Birth date: Soc. Sec. #: Employer: Home phone: Work phone: Cell phone: Is this person currently a patient in our office? INSURANCE INFORMATION Name of insured Relationship Birth date: Soc. Sec. #: Date employed: Employer: Work phone: Insurance Company Group # Employee ID
Do you have any secondary insurance?: If yes, complete the following: Name of insured Relationship Birth date: Soc. Sec. #: Date employed: Employer: Work phone: Insurance company Group # Employee ID FINANCES Payment in full is expected at each appointment. For your convenience, we offer the following methods of payment. Please check the option which you prefer. If you have any questions concerning financial arrangements, it will be our pleasure to assist you. Cash Personal check American Express Visa Master Card Care Credit Discover CERTIFICATION AND ASSIGNMENT To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to me (or my dependent) during the period of such dental care, to third party payers and/or health practitioners. I authorize and hereby request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. Signature of patient, parent, guardian, or personal representative Date Please print name of patient, parent, guardian, or personal representative Relationship to patient CANCELLATION POLICY We strongly believe everyone s time is valuable. We kindly request 24 hours notice in the event that you need to cancel an appointment to avoid a cancellation fee.
PATIENT MEDICAL HISTORY Patient name: Physician: Office phone: Date of last exam: Medical alert: 1. Are you under medical treatment now? 2. Have you ever been hospitalized for any surgical operation or serious illness? 3. Do you/have you in the past used cocaine and/or other drugs? 4. Do you wear contact lenses? 5. Are you taking any medication(s) including non-prescription medicine? If yes, what medication(s) are you taking? 6. Are you allergic to or have you had any reactions to the following: Local anesthetics Penicillin or other antibiotics Sulfa drugs Barbiturates Sedatives Iodine Aspirin Latex Other: 7. Women Only: Are you pregnant or think you may be pregnant? Are you nursing? Are you taking birth control pills? 8. Do you have or have you had any of the following? High blood pressure Heart Disease Heart attack Cardiac pacemaker Rheumatic fever Heart murmur Swollen ankles Angina Fainting/seizures Frequently tired Asthma Anemia Low blood pressure Emphysema Epilepsy/convulsions Cancer Leukemia Arthritis Diabetes Joint replacement or implant Kidney disease Hepatitis/jaundice AIDS or HIV infection Sexually transmitted disease Thyroid problem Stomach troubles/ulcers None of the above conditions/no medical conditions Chest pains Easily winded Stroke Hay fever/allergies Tuberculosis Radiation therapy Glaucoma Recent weight loss Liver disease Heart trouble Respiratory problems Other I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. Signature: Date: Patient, parent or guardian
PATIENT DENTAL HISTORY & QUESTIONNAIRE Patient name: Date of last dental exam: Medical alert: 1. Are your teeth sensitive to hot or cold liquids/foods? 2. Are your teeth sensitive to sweet or sour liquids/foods? 3. Do you feel pain to any of your teeth? 4. Do you bite your lips or cheeks frequently? 5. Have you ever had any difficult extractions in the past? 6. Have you ever had prolonged bleeding following extractions? 7. Do you have trouble chewing your food? 8. Do you chew on one side of your mouth? 9. Do you have loose teeth or broken fillings? 10. Are you missing any teeth? 11. Are you a mouth breather? 12. Do you have any sores or lumps in or near your mouth? 13. Have you had any head, neck or jaw injuries? 14. Have you ever experienced any of the following problems in your jaw? Clicking or popping? Pain (joint, ear, side of face)? Difficulty in opening or closing? Difficulty in chewing? 15. Have you noticed that your teeth have chipped/shifted in the last few years? 16. Do you have frequent headaches? 17. Do you clench or grind your teeth? 18. Have you had any orthodontic work? 19. Do you wear any kind of retainer during the day/night? 20. Do you have bad breath? 21. Do your gums bleed while brushing or flossing? 22. Do you use a rotary toothbrush? 23. Have you ever had instruction on the correct method for brushing your teeth and the care of your gums? 24. Have you ever had periodontal treatment for: Debridement/deep cleaning? Periodontal/gum surgery? 25. Do you brush your teeth and gums too hard? 26. Are you happy with the way your teeth look? 27. How would you describe your smile? Great Average I don t smile much I never really thought about it 29. Are you pleased with the color of your teeth? 30. Have you ever whitened your teeth?
31. Do you have unsightly crowns or fillings? 32. Are your teeth too short or too long? 33. Are there any gaps between your teeth that you do not like? 34. Are you interested in cosmetic dentistry which may include orthodontics (braces) as an option? 35. Is there anything about your smile that you would want to change if you could? Yes No 36. Do you drink: Coffee Tea Red wine 37. How much and how often per week? 38. Do you currently smoke: Cigarettes? Cigars? 39. How many/day? Years smoked? * If you have quit smoking in the past, how many years did you smoke? When did you quit and how much were you smoking per day then? 40. Do you/have you in the past used cocaine and/or other drugs? 41. Have you ever been treated for substance abuse? 42. Do you currently have or in the past had an eating disorder? Yes please specify No 43. Do you have anxiety about your dental visits? What is the reason for your visit today? What was done at your last dental visit? Do you have any dental problems now? If yes, please describe: Do you brush, floss, or use any dental aides? Please list: Is there anything else about having dental treatment that you would like us to know? If yes, please describe: I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. Signature: Date: Patient, parent or guardian