Patient Information Patient's Name :Date of Birth :Sex :Marital Status :SSN :Spouse's Name :Employer :Previous Dentist Name :Previous Dentist City, State :Previous Dentist Phone :Physician Name :Physician City, State :Physician Phone :Nearest Relative not living with you :Relationship :Who referred you to us? :Person Responsible for Account Name :Social Security Number :Home Phone :Cell Phone :Street Address :City, State, Zip Code :Mailing Address, if different :Employer :Business Address :Business City, State, Zip :Business Phone :Business Dept. :Job Title :Bank :Account Type :Credit Reference #1 :Credit Reference #2 :Dental Insurance Information Dental Insurance Company's Name :Employee's Name :Employee's SSN :Dental Insurance The responsibility for fees incurred is that of the Patient and not of the insurance company. However, as a convenience, we will gladly process your claim but we request that you pay your estimated portion when services are rendered, and also provide a signed, completed and assigned benefits dental claim form. Payment 1. If you have no insurance, payment in full is due at the time of your visit. 2. MasterCard, VISA, Discover, AmEx are accepted. 3. The party submitting this form accepts or shares responsibility for the payment of the balance of this account. I understand that any remaining balance is due when billed and that any unpaid balance thereafter incurs a 1½% service charge (18.0% Annual Percentage Rate) for each month until the balance is paid. There will be a charge for missed or broken appointments. We require a 24 hour notice of cancellation. The charge is $35.00 or 10% of the procedure scheduled, whichever is greater. Medical Health GENERAL HEALTH :Date of last complete physical exam :Are you taking any medication now? :If yes, for what purpose? :Are you taking any herbs? :Have you ever been treated for: Heart Disease :Rheumatic fever :Abnormal Blood Pressure :Ulcers :Tuberculosis or lung disease :Diabetes :Epilepsy :Anemia :Congenital heart lesions :HIV Positive :Heart Murmur :Jaundice :Asthma or hay fever :Sinus Trouble :Cough :Hepatitis :Arthritis :Stroke :Glaucoma :AIDS :Have you ever been treated (other than diagnostic) with x-ray? :Are you allergic to: Penicillin :Codeine :Local injected anesthetics :Allergic to other medications :Are you subject to prolonged bleeding? :Are you subject to fainting spells? :Do you have excessive urination and/or thirst? :Do you have frequent headaches? :Do your jaws pop or click? :(Women) Are you pregnant? :If so, how long? :Blood Pressure :What is the reason for this visit? :Please add anything you feel you should :Dental Health Have you ever had any serious problem associated with previous dental treatment? :If so, explain :How often do you brush your teeth? :What texture brush do you use? :What brand? :How often do you floss? :Do your gums bleed while brushing? :Do your gums bleed while flossing? :Do you avoid brushing any part of your mouth due to pain? :If yes, what part? :Do you feel twinges of pain when your teeth come in contact with: hot foods or liquids :cold foods or liquids :sweets (candy, fruit, etc.) :sours (lemons, limes, etc.) :Do you feel pain to any of your teeth when brushing or flossing? :If yes, explain :Do your gums feel tender or swollen? :Do you clinch or grind your jaws while sleeping or during the day? :Do your jaws ever feel tired? :Do you wear dentures? :Do you usually have many cavities? :Do you lose or break fillings? :Do you gag easily? :Are you familiar with the term "preventive dentistry"? :Please add anything you feel is important :
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