Online New Patient Forms

Name:

Date

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Date of Birth:

Age:

Email:

Previous Occupation:

Occupation:

Work Phone:

Place of Employment:

Marital Status:

Spouse’s name:

Emergency contact

Phone #:

Dentist:

Phone #:

Physician:

Phone #:

Whom may we thank for referring you to our office?

Who is financially responsible for this bill?

How will the services be paid?

Cash

Check

Credit Card

Debit Card

Signature:

Parent/legal guardian

Date:

DENTAL HISTORY

1. Chief Complaint? (What brings you to our office?)

2. Are you in pain today?

Yes No

If yes, SELECT your pain level:

Mild Moderate Severe Worst Pain

Please describe your pain:

3. Are you taking any specific OTC or Prescription medications for this dental condition?

Yes No

If so, what are you taking?

4. Do you have fear or anxiety when going to the dentist?

Yes No

If yes, what is your anxiety level:

Mild Moderate Severe

5. Are you required to take an antibiotic pre-medication prior to any dental treatment?

Yes No

If yes, what medication do you take?

What do you take this premed for?

6. Do you have chronic dental or facial pain?

Yes No

7. Have you been treated for “TMJ” in the past?

Yes No

8. Do you grind or clench your teeth?

Yes No

9. Do you get chronic headaches?

Yes No

10. Have you been diagnosed with migraines?

Yes No

11. Have you had any facial trauma (car accident, sports injury, fall?)

Yes No

12. Have you ever had facial esthetic treatments (Botox, dermal fillers, medical or Medspa skin treatments?)

Yes No

13. Would you like information on the facial esthetic treatments we offer at this office?

Yes No

Please check what you would be interested in:

Botox

Peels

Filler

Threads

Skin rejuvenation

Energy treatments

When would you be available to talk about facial aesthetics?

MEDICAL HISTORY

14. In the last three years, have you been hospitalized or had a serious illness?

Yes No

If yes, please explain?

15. Have you ever taken Bisphosphonates that are used to treat osteoporosis (such as Fosamax, Zometa, or Boniva?)

Yes No

If yes, which did you take, and how long has it been since you’ve taken it?

16. Are you under the care of a physician now?

Yes No

If yes, for what?

17. When was your last physical examination?

Women only:

18. Is there any chance you may be pregnant?

Yes No

19. Are you taking birth control pills?

Yes No

20. Are you nursing?

Yes No

Any additional medical information that you would like to provide?

Please list ALL medications you are currently taking and what each medication is for. (Including OTC, herbs, and vitamins)

Medication

Taking for?

Taking for...

10)

Taking for...

11)

Taking for...

12)

Taking for...

13)

Taking for...

14)

Taking for...

15)

Taking for...

Please list ALL allergies you have, particularly to any medications or drugs.

Allergies

10)

To the best of my knowledge, I have answered every question completely and accurately, and I will inform my dentist of any changes in my health and/or medications.

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/Guardian Signature

Date

HIPAA Consent (For Use or Disclosure of Health Information) This form must be completed by the individual whose protected health information is to be disclosed or by a parent or guardian if the person is a minor under state law.

Name of Patient:

By signing this form you give permission to Dr. Sardzinski, (Venice Endodontics) to correspond and disclose person information via mail, E-mail, phone or fax to:

Referring Dentist and or General Dentist
Prescriptions, diagnostic, treatment, and or care management services
Other (I.E spouse/children/specify)

The above information may be released by:

Add Additional Name

I want this consent to:

Continue Indefinitely

Effective Only Until (date):

Effective Only Until:

I understand that consent may be revoked by me at any time. I understand why I have been asked to disclose this information and am aware that my patient rights are identified in the practice’s Notice of Privacy Practices.

Signature of Patient

Date

Or, Personal Representative

Date

Your information will be encrypted.