Patient Information Form

We warmly welcome you to our office. Please take a few moments to complete the following information so that we can better care for you. It is our goal to help you reach and maintain maximum oral health

Patient's Name

I prefer to be called

Date of Birth

SSN #

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email address

How do you prefer to confirm your appointments?

Employer

Occupation

Whom may we thank for referring you

Other family members seen by us?

Previous / Present Dentist

Date of Last Visit

In the event of an emergency, whom should we contact?

Name

Relationship

Work Phone

Home Phone

Dental Insurance

Insurance co. name

Home Phone

Group or Policy #

Insured's Name

Insured's Employer

Relation

Insured Birthdate

Insured SSN or ID #

Secondary Dental Insurance

Insurance co. name

Home Phone

Group or Policy #

Insured's Name

Insured's Employer

Relation

Insured Birthdate

Insured SSN or ID #

FINANCIAL INFORMATION

A note for patients with dental insurance – We will assist you to maximize your insurance benefits, and we are happy to file claims to your insurance carrier and agree to accept payment from any carrier that offers an assignment of benefits, if you desire. We will do our best to calculate your available benefit amount, however, regardless of what your insurance plan pays, you are responsible for all fees.

Medical History

Are you currently under the care of a physician?

Yes No

If yes, please explain

Please list ALL medications and supplements

Do you use or smoke tobacco in any form?

Yes No

Have you or do you take Redux/Fen Phen or Pondimin?

Yes No

Are you pregnant?

Yes No

Trimester?

Have you ever taken Fosanax, Boniva, or any other medications containing Bisphosphonates

Yes No

Please list any serious medical condition (s), surgeries, or reason for being hospitalized that you have ever had

Are you allergic to any of the following items?

Please list any other drugs you are allergic to

Dental History

Why have you come to the dentist today?

Many patients consult us for a 2nd opinion. Are you currently seeing another dentist for your dental needs?

Yes No

If Yes, please explain

How often do you brush your teeth?

Floss

Do your gums bleed when you floss?

Yes No

Do your gums bleed when you brush?

Yes No

Have you ever experienced pain in you jaw joint?

Yes No

Have you ever been treated for TMJ symptoms?

Yes No

If yes, please explain

Do you grind or clench your teeth?

HIPPA Compliance Statement:
Your health information may be used in our office to conduct scheduling and coordination of care between the doctor, dental assistant, hygienist, business staff and other health care providers. We may include your health information (including x-rays) with communications related to your treatment and we may do this with insurance forms filed via mail or electronically. We may communicate with you via phone, messages, postcards/letters, or electronically.

MEDICAL HISTORY:
I understand that this information is correct to the best of my knowledge. I understand it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

CONSENT:
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I give permission for the doctor or their staff to use any photos taken for lecturing, publishing, educational, or promotional purposes.

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.

Signature

Date

Patient portion is due in full at the time of treatment

Your information will be encrypted.