Patient Information Form

Patient Information

First Name:

Middle Initial:

Last Name:

Preferred Name:

Sex:

Male Female

Marital Status:

Married Single Other

If other, please specify:

Birth Date:

Social Security #:

Driver License #:

Home Phone #:

Work Phone #:

ext:

Mobile Phone #:

E-Mail:

Address:

Street:

Apartment #:

City:

State:

Zip Code:

In case of an emergency, contact:

Relationship:

Phone #:

Referral Information

How did you know about our practice?

Patient

Relative

Specialist Office

Insurance

Internet

School

Work

Other

Name of person or office referring you to our practice:

Health Information

Date of Last Dental Visit:

Reason for seeing Dr. Atashbar today:

Have you ever had any of the following?

HIV/AIDS

Yes No

Allergies

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Cancer

Yes No

Diabetes

Yes No

Dizziness

Yes No

Epilepsy

Yes No

Emphysema

Yes No

Excessive Bleeding

Yes No

Fainting

Yes No

Glaucoma

Yes No

Growths

Yes No

Hay Fever

Yes No

Head Injuries

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Hepatitis (A,B,C,D,E)

Yes No

High Blood Pressure

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Mental Disorders

Yes No

Mitral Valve Prolapse

Yes No

Nervous Disorders

Yes No

Pacemaker

Yes No

Radiation Treatment

Yes No

Currently Pregnant

Yes No

Due Date:

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Sinus Problems

Yes No

Stomach Problems

Yes No

Stroke

Yes No

Tuberculosis

Yes No

Thyroid

Yes No

Tumors

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

HPV

Yes No

Penicillin Allergy

Yes No

Tetracycline Allergy

Yes No

Nitrous Allergy

Yes No

Latex Allergy

Yes No

Sulfa Allergy

Yes No

Aspirin Allergy

Yes No

Local Anesthetic Allergy

Yes No

Other Allergies:

Flu

Yes No

Drug/Alcohol Abuse

Yes No

Do you need to pre-medicate with antibiotics prior to dental treatment?

Yes No

If yes, please explain:

Are you currently taking any medications:

Yes No

If yes, please list:

Are you taking BISPHOSPONATE medications (Fosamax, Boniva, Aredia, etc.)?

Yes No

Have you ever had any complications following dental treatment?

Yes No

If yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years?

Yes No

If yes, please explain:

Are you now under the care of a physician?

Yes No

If yes, please explain:

Name of Physician:

Phone:

Do you have any health problems that need further clarification with your Physician?

Yes No

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.

Signature of patient, parent, or guardian:

Today's date:

Doctor’s Signature:

Employment Information (Required)

Employer’s Name:

Occupation:

Address:

Street:

City:

State:

Zip Code:

Insurance Information (Required)

Subscriber of Insurance:

Relationship to patient:

Insurance Co. Name:

Telephone Number:

Contract ID#/Subscriber ID#:

Group #:

Employer’s Name:

Insurance Address:

City:

State:

Zip:

IS PATIENT COVERED BY ADDITIONAL INSURANCE

Yes No

Subscriber of Insurance:

Relationship to patient:

Insurance Co. Name:

Telephone Number:

Contract ID#/Subscriber ID#:

Group #:

Employer’s Name:

Insurance Address:

City:

State:

Zip:

Responsible Party Information (Required)(Person Responsible for Payment)

Name:

Relationship to patient:

Social Security #:

Birth Date:

Home Phone #:

Work Phone #:

Address:

Street:

City:

State:

Zip Code:

PATIENT TREATMENT CONSENT

I authorize the Dentist or designated staff treating me to perform such diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize the Dentist to perform all recommended treatment and therapeutic procedures to include administering medications as prescribed by the Dentist and mutually agreed upon by me.

I assign all dental insurance benefits to which I am entitled to the extent permitted under my dental insurance policy(s) to the Dentist. This form also authorizes this Practice to submit insurance claim forms and receive payment directly from the Insurance Carrier with the notation “SIGNATURE ON FILE”. I authorize my Dentist to release treatment records/x-rays or any other information deemed pertinent to my insurance carrier as necessary and/or requested.

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree that any unpaid claims the carrier does not pay or any balance that extends beyond 45 days from the date of treatment might be assessed to a service charge and/or turned over to a collection agency. I am aware that if my account is turned over to a collection agency, I will be responsible to pay 25% collection agency fees and/or $50.00 court costs or attorney fees.

I have read the above conditions of treatment and payment and agree to their content.

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 of patient, parent or guardian:

Date:

The interested parties may revoke this authorization in writing only.
Please note once records are established there is a $35.00 charge for duplication of records including x-rays.
Charges will apply for missed or canceled appointments without proper notification.

Your information will be encrypted.