Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single Child Other Soc. Sec #: Email: Referred by: Last Dentist: Date of Last Dental Visit:: Emergency Contact: Who will be responsibility for your account? Self Spouse Parent Other Name: _ SS #: DOB: Address: Street City State Zip Code Phone #: Cell #: Employer Name and Address: Employer Tel. #: Drivers Lic. #: Insurance Information Name of Insured: DOB: Insurance Company: Phone: Employer: Emp. Phone# : Emp. Address: ID #: Group #: Patients relationship to insured: Self Spouse Child Other
Patient Name: Secondary Insurance Information Name of Insured: DOB: Insurance Company: Phone: Employer: Emp. Phone# : Emp. Address: ID #: Group #: Patients relationship to insured: Self Spouse Child Other Financial Policy We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full at the time of the visit, unless other arrangements have been made with the business manager. If an account is not paid within 90 days of the date of service or financial arrangements have not been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims in compliance with HIPPA standards. To the best of my knowledge, all of the preceding answers and information provided are true and correct. Patient (guardian) signature Date I hereby acknowledge that a copy of this office s Notice of Privacy Practices in compliance with HIPPA has been made available to me. I have been given the opportunity to ask any questions I may have regarding this notice. Patient (guardian) signature Date FOR OFFICE USE ONLY:
Patient Name: Practice Name Here DENTAL HEALTH HISTORY Reason for today s visit: Exam Emergency Consultation Are you in pain: Yes No For how long: Do you require pre-medication: Yes No Don t know Previous Dentist: Name Tel # Date of Last Dental Exam: Date of last X-rays : Do you have copies Yes No Times a Day you Brush: Times a week you Floss: How would you rate your smile? 1 2 3 4 5 6 7 8 9 10 (best) Have you ever had complications after dental care: Yes No If yes, please explain: In the dental office have you ever had Nitrous Sedation? Yes NO, Oral sedation? Yes No, General Anesthesia? Yes No Is there a specific area of dental treatment you believe you need? Yes No Explain: Would you like to discuss options to improve your smile? Yes No Have you ever had your teeth whitened? Yes No If yes, what method(s)? Do you have any Dental Implants? Yes No Please indicate any of the following problems by checking off the corresponding box Discomfort, clicking or popping in the jaw Red swollen or bleeding gums Sensitive tooth, teeth or gums Blisters/sores around the mouth Lost /Broken Filling(s) Teeth grinding/clenching Ringing in ears Broken/chipped teeth Stained Teeth Locking jaw Bad Breath Burning tongue Difficulty closing jaw Swelling/lumps in mouth Loose/shifting teeth Food caught between teeth My teeth are sensitive to: Hot Cold Sweets Biting Other: TMJ/TMD, If so do you wear a mouth guard/night guard? Have you ever had your teeth equilibrated/adjusted? Yes No Do you have Dental Anxiety or fear of treatment? Yes No If yes, how have you handled it in the past: MEDICAL HEALTH HISTORY Are you in good health: Yes No Primary Care Physician: Dr. Tel. # Have you had any illness, operation, or been hospitalized in the past 5 years: Yes No If Yes, explain: Are you taking any of the following medications: Muscle relaxers Nerve Pills Pain Killers (including aspirin) Stimulants Blood Thinners Tranquilizers Insulin/Diabetes Meds Herbal supplements If so, list purpose Other (please list and state purpose)
Patient Name: Do you have or have you had any of the following diseases, medical conditions or procedures? Y N Y N Y N Y N Heart Attack / Stroke Heart Surgery / Pacemaker Angina Internal Defibrillator Heart Stint Heart Murmur HIV / AIDS / ARC Mitral Valve Prolapse Artificial Valves Heart Disease Congenital Heart Defect Chest Pains Thyroid Problems Kidney Problems Rheumatic Fever Respiratory Problems Scarlet Fever Liver Problems Asthma Sinus Problems Stomach Problems Psychiatric Problems Venereal Disease Alcohol / Drug Abuse Cancer / Tumors Shingles Tuberculosis Nervousness Hepatitis Chemotherapy Arthritis / Rheumatism Difficulty Breathing Emphysema Fainting / Seizures / Epilepsy Severe / Frequent Headaches Frequent Neck Pain Cosmetic Surgery X-Ray / Cobalt Treatment Diabetes / Hypoglycemia Leukemia High / Low Blood Pressure Bleeding Problems Anemia Glaucoma Artificial Bones / Joints Eating Disorder / Anorexia / Bulimia Back Problems Please list any other medical conditions you have or ever had: Are you allergic to the following: Latex Penicillin/Amoxicillin Tetracycline Aspirin Sulfites Sulfa Drugs Dental Anesthetics Others: Do you use tobacco? Yes No / If yes how much and how long? Please rate your general health from 1-10 (10 = excellent)? 1 2 3 4 5 6 7 8 9 10 (best) Have you ever taken the Phen-fen or Redux? Yes No Do you wear contact lenses? Yes No For Women: Are you taking Birth Control Pills? Yes No Are you Pregnant: Yes No If so, Due Date: How many children have you had? Are you nursing? To the best of my knowledge all of the preceding answers and information provided are and true and correct. If I ever have any change in my health, I will inform the dental office at the next appointment without fail. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims and consult with referring doctors in compliance with HIPPA standards. / / Signature Patient Guardian Date Office Use Only Notes:
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} For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify) 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form is educational only, does not constitute