NEW PATIENT FORMS

CONFIDENTIAL PATIENT INFORMATION

Thank you for selecting our office! We at Mark Paden’s office will strive to provide you with the best possible dental care with options to improve your smile. To help us meet all your dental needs, please fill out this form completely in ink. If you have any questions or need assistance, please feel free to ask for any help you may need and we will be happy to be of assistance.

Patient Name:

Date of Birth:

SS #:

Mailing Address:

City:

State:

Zip:

Home #:

Work #:

Cell #:

Email:

Student Attending School

Not Attending School

Full Time

Part Time

Name of School:

Please Check One:

Minor Single Married Divorced Separated Widowed

Whom may we thank for referring you to our office?

In Case of Emergency Please Contact:

Phone #:

RESPONSIBLE PARTY (if other than patient must be parent or guardian in attendance at initial visit)

Name:

Relationship to Patient:

Date of Birth:

Address:

City:

State:

Zip:

Email:

Is this person currently a patient in our office?

For your convenience we have the following methods of payment. Payment in full at each appointment. Please check the option you prefer:

Cash Check Visa Mastercard Care Credit

INSURANCE INFORMATION (please give insurance card to front desk to make a copy for our records)

Name:

Relationship to Patient:

Date of Birth:

Billing Address:

City:

State:

Zip:

Home #:

Work #:

Cell #:

SS or ID #:

Employer:

Employer Address:

CIty:

State:

Zip:

Insurance Company:

Phone #:

Group #:

Insurance Address:

City:

State:

Zip:

Insurance billing is done as a courtesy service; all balances are the responsible party’s responsibility.
PLEASE ALSO FILL OUT HEALTH HISTORY ON THE NEXT 2 PAGES WITH SIGNATURE

CONFIDENTIAL HEALTH HISTORY

Please Check the Appropriate Answers (Leave blank if you do not understand the question)

1. Is your general health good?

Yes No

If no, please explain:

2. Are you taking any medications or supplements?

Yes No

If yes, please list them below:

3. Are you being treated by a physician now?

Yes No

If yes, please explain:

4. Have you had problems with prior dental treatment?

Yes No

If yes, please explain:

Date of Last Dental Exam:

Name of Last Dentist:

Address and Phone of Last Dentist

5. Are you In pain now?

Yes No

If so, what is your primary concern?

If you are female, please answer the following:

Are you taking birth control pills?

Yes No

Are you pregnant?

Yes No

If yes, # of weeks

Are you nursing?

Yes No

Do you smoke tobacco?

Yes No

Height:

Weight:

Conditions

Abnormal Bleeding

Yes No

Alcohol Abuse

Yes No

Allergies

Yes No

Anemia

Yes No

Angina Pectoris

Yes No

Arthritis

Yes No

Artificial Bones

Yes No

Artificial Heart Valve

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Cancer - Chemotherapy

Yes No

Colitis

Yes No

Congenital Heart Defect

Yes No

Cosmetic Surgery

Yes No

Diabetes

Yes No

Difficulty Breathing

Yes No

Drug Abuse

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting Spells

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

High Blood Pressure

Yes No

HIV+ AIDS

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Mitral Valve Prolapse

Yes No

Pace Maker

Yes No

Pneumocystitis

Yes No

Psychiatric Problems

Yes No

Radiation Therapy

Yes No

Rheumatic Fever

Yes No

Seizures

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Allergies

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetics

Yes No

Erythromycin

Yes No

Jewelry

Yes No

Latex

Yes No

Metals

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Other:

Are you suffering from any of the following signs or symptoms of aerosol transmissible illness?
Please mark (yes) or (no) for each question:

1. Do you currently have a respiratory illness?

Yes No

2. Have you had a cough for at least 3 weeks not explained by noninfectious conditions?

Yes No

3. Have you had coughing fits that interfere with eating, drinking, talking or breathing?

Yes No

4. In addition to cough, are you currently experiencing or experienced recently:

a. Unexplained weight loss (more than 5 lbs)

Yes No

b. Night sweats

Yes No

c. Fever

Yes No

d. Chronic fatigue or malaise

Yes No

e. Painful, swollen salivary glands

Yes No

f. Unexpected rash

Yes No

g. Stiff neck

Yes No

6. Do you have, or have you had any diseases or medical problems NOT listed on this form?

Yes No

If Yes, Please Explain

7. Have you ever been pre-medicated for dental treatment?

Yes No

If Yes, why?

8. Have you ever taken Fen-Phen?

Yes No

If yes, when?

9. Is there any issue or condition that you would like to discuss with the Dentist in private?

Yes No

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician.

Physician’s Name:

Phone Number:

Pharmacy of Choice:

Phone Number:

AUTHORIZATION

I certify that I, and/or my dependent(s), have insurance coverage with (insert Insurance Provider below) and I assign directly to Dr. Mark Paden all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

I certify that I have read and understand this form. To the best of my knowledge, I have answered everything completely and accurately. I will inform Dr. Paden of any changes in my health and/or medications. I also understand that there will be a charge for failed appointments and/or canceled appointments without a 24 hour notice. Further, I will not hold Dr. Paden, or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.

Insurance Provider:

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

Signature of Patient (Parent or Guardian)

Date:

Your information will be encrypted.