Patient information

First Name:

MI:

Last:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth:

Gender:

Male Female

SS#:

Address:

City:

State:

Zip:

Employer:

State ID/Drive's License #:

E-mail Address:

Name of Physician:

Physician Phone:

In case of Emergency Contact:

Relationship:

Phone:

How did you hear about our office?

Patient Health History

Do you have a history of:

Radiation Treatment

Yes No

Medical Questions

List any medications you are taking including nonprescription drugs:

Do you have any disease/problem you think we should know about?

Are you allergic to any medications?

have you ever been hospitalized?

Are you in good health?

Yes No

Date of last medical exam:

Have you had a transplant operation that has depressed your immune system?

Yes No

Have you had an allergic reaction to Bananas?

Yes No

Do you smoke or chew tobacco?

Yes No

Have you had Heart Surgery?

Yes No

Are you now under the care of an MD?

Yes No

Are you taking or have you ever taken bisphosphonates? (Fosamax or Actonel for osteoporosis, chemotherapy, etc)

Yes No

FOR WOMEN ONLY:

Are you taking birth control pills?

Yes No

Are you nursing/breastfeeding?

Yes No

Are you pregnant?

Yes No

Expected delivery date:

Is there a possibility of pregnancy?

Yes No

Dental History Information

Date of last dental visit?

Do you snore?

Yes No

Name of your previous dentist

Do you have problems with bad breath?

Yes No

Reason for today's visit?

Have you ever had an allergic reactions to a crown, metal filling or dental appliance?

Yes No

How often do you floss your teeth?

Have you ever had an oral cancer screening?

Yes No

Do your gums bleed when you brush?

Yes No

Have you or a family member ever been treated for periodontal disease?

Yes No

Have you ever used an electric toothbrush?

Yes No

Are your teeth sensitive to hot, cold or pressure?

Yes No

Have you ever had complications from an extraction?

Yes No

Have you ever had a popping or clicking near your ear when you chew?

Yes No

Are you prone to frequent headaches?

Yes No

Do you grind or clench your teeth?

Yes No

Do you have sores, blisters or swelling on your gums lips or cheeks?

Yes No

Have you ever had orthodontic treatment?

Yes No

If you could change something about your smile what would it be:

Whiter

Straighter

Close space

Replace black mercury filling with tooth colored restorations

Repair chipped teeth

Replace missing teeth

Less gums showing

Replace old crowns or caps that don't match

I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient:

Date:

Parent/Guardian (if patient is a minor):

Date:

PAYMENT ARRANGEMENT FORM

Name of Patient:

Payment Agreement:

I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

RESPONSIBLE PARTY:

Full Name:

Date of Birth:

SSN#:

Street Address:

City:

State:

Zip:

Home Phone:

Work phone:

Employer Name:

INSURANCE INFORMATION:

Primary Insurance:

Primary Insurance Name:

Address:

Phone Number:

Name of Insured:

Relationship:

ID Number:

Group Number:

Secondary Insurance:

Secondary Insurance Name:

Address:

Phone Number:

Name of Insured:

Relationship:

ID Number:

Group Number:

I acknowledge having received a copy of the Practice’s Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

E-Signature of Responsible Party:

Date:

Your information will be encrypted.