Health History Form

Patient Name

Birthdate

Parent/Guardian

Street Address

City

State

Postal Code

Phone - Home

Cell

Phone - Work

MSI Health Card Number

(For children 15 and under)

Dental Insurance Benefits Provider

(Ex. Blue Cross)

Group Insurance Holders Name

(If Different From Above, ex. Spouse or Parent)

Date of Birth

Policy Number

Identification Number

Emergency Contact

Emergency Contact Phone #

New Patients

How did you hear about us

Website Walk In/Signage Sporting Event Sponsor Facebook Instagram Friend/Family Referral Google Other

If other, please specify

Health History

Are you having any dental/oral discomfort at this time?

Yes No

Previous Dentist

Date of Last Dental Exam

Date of Last Dental X-Rays

Date of Last Hygiene Appointment

What was done at that time?

What is the reason for your Dental Visit today?

Have you had any of the following? Select all that apply

Dentures

Braces

Bite Planes

Treatment for Gum Disease

Trauma to the Head or Neck

N/A

Are you in good health?

Last date of physical exam?

Are you being treated by a physician now?

Yes No

Are you currently taking any medications?

Yes No

Have you ever been told you need a Pre-Med prior to Dental Treatment?

Yes No

Do you have any allergies?

Yes No

Are you allergic to any of the following drugs? Please Check All That Apply

Local Anesthetic

Barbiturates, Sedatives, Sleeping Pills

Penicillin

Aspirin

Other

Not Applicable

If other, please specify

Are you allergic to latex?

Yes No

Have you ever taken medication for osteoporosis or bone density? (Group of drugs used to slow down or prevent bone loss/strengthening bones)

Yes No

Have you ever had excessive bleeding?

Yes No

Are you currently on any blood thinners or anticoagulants?

Yes No

Have you had surgery within the last five years?

Yes No

Have you ever been treated for a tumor or skin disease?

Yes No

Has anyone in your family ever had diabetes?

Yes No

Has anyone in your family had heart disease?

Yes No

Do you take medication for high cholesterol?

Yes No

Do you smoke/chew tobacco?

Yes No

Do you clench or grind your teeth?

Yes No

Do you use recreational drugs or cannabis? Please let the hygienist and/or dentist know of any past or current drug use

Yes No

Who is your Family Doctor?

Phone #

Women Only

Are you pregnant?

Yes No

Have you reached Menopause?

Yes No

Other Information

Is there anything else in your health history we should know?

Do you have any concerns regarding your dental health?

Form Filled by

Patient Parent Guardian

Consent/Agreement

Patient Consent

It may become necessary to refer you to a specialist at some time. In this event, we would be required to provide your personal information, i.e. name; address; date of birth and insurance details. Please sign below indicating your permission for this office to share your personal information for such purpose. Personal information is shared ONLY with professionals who will be treating you on our behalf. I agree to having my personal information disclosed to and discussed with my immediate family, should it become necessary.

Agree/Disagree

Agree Disagree

Confidentiality Policy

We take your privacy very seriously and have policies in place to safeguard your personal information.

If you have dental insurance, it will be necessary for us to share some personal information (i.e. name, address, date of birth, treatment provided, and insurance details) in order to process your claim.

It may become necessary to refer you to a specialist at some time. If you agree to such a referral, we would be required to provide the specialist's office with the above information, as well as your pertinent dental and medical history. Personal medical and dental information is shared ONLY with professionals who will be treating you on our behalf.

In the unlikely event of a medical emergency, we may need to contact and share information with immediate family members or your emergency contact person.

Please initial below indicating permission for this office to share your personal information, only as described above.

I understand and agree to the Confidentiality Policy outlined above.

Inital

Payment Policy

In an effort to continue to provide quality care and convenience to our valued patients, we will send your insurance claims electronically, thereby allowing us to advise you of the unpaid amount.

We would appreciate the amount not covered by your insurance to be paid in full by you at the time of your appointment.

If you are not covered by dental insurance, we would appreciate receiving payment at the time of your appointment.

If you would like to settle your account by credit card, please advise the receptionist of the number.

Any other payment options should be discussed with the dentist.

I have read and agree with the payment options and patient consent policy above.

Consent/Agreement

Acknowledgment of Cancellation Policy

At Alliance Dental we understand that your life is busy and know that occasionally you may need to reschedule or change your appointment time.

Please keep in mind that when we schedule your appointment, we reserve this time especially for you and book our dental professionals to be available for your treatment. If you cancel without notice we lose two appointments, your appointment and the person who would have been scheduled for that time slot.

Please carefully read the following Cancellation Policy:

I am responsible for providing 24-hours notice of appointment cancellations.

Consent/Agreement

Your information will be encrypted.