Patient information

Name ___________________________________ Social Security # __________________ Address____________________________ City___________________ Zip Code ______ Home Phone ( ) ________________ Work Phone ( )_________________________ Cell Phone ( ) __________________ Email Address ___________________________ Sex M F Age _____ Date of Birth ____________ Marital Status _____________ Referred by_______________________________ Reason for visit ___________________ Name of Dentist______________________ Name of Physician ______________________ In case of emergency who should be notified? _____________________ Phone _________ MEDICAL HISTORY
Has there been any change in your general health within the last year? Yes No
Are you now under the care of a physician? Yes No
If yes, what is the condition for which you are being treated? ________________________
Have you ever had an operation? Yes No If yes, what type ____________________
Have you been hospitalized or had a serious illness during the past 5 years? Yes No
If so, what was the problem? _________________________________________________
Have you ever had a blood transfusion? Yes No
Have you ever been denied permision to give blood? Yes No If so, why? _________
Have you had contact with individuals having hepatitis, tuberculosis, or AIDS? Yes No
Do you premedicate with antibiotics prior to a dental procedure? Yes No
If so, for what reason? ______________________________________________________
Are you pregnant? Yes No Taking birth control pills? Yes No
Have you reached menopause? Yes No Taking any hormones? Yes No
Please check if you have or have had any of the following:
Do you bruise easily? Yes No Do you have a blood clotting disorder? Yes No Do you bleed excessively after a cut? Yes No Do you have a family history of heart problems, diabetes, skin diseases? Yes No ORAL HEALTH HISTORY
Do you have a history of:
Fever blisters, cold sores, recurrent canker sores, mouth ulcers or herpes? Yes No
Trouble with previous dental treatment? Yes No
Bleeding excessively after extractions, surgery or wounds? Yes No
Frequent dry mouth? Yes No
Surgery or radiation for a tumor, growth, cancer of your head, neck or mouth? Yes No
Any disease, problem or condition not listed? Yes No
If so, please specify_________________________________________________________
Are you currently taking any of the following drugs?
Anticoagulants – Persantin, Coumadin, Ecotrin, Plavix, or an Aspirin Daily? Yes No
Medicine for high blood pressure or water pills? Yes No
Cortisone or Steroids? Yes No
Valium, Librium or other tranquilizers? Yes No
Wellbutrin or other antidepressants? Yes No
Insulin or pills for Diabetes? Yes No
Digitalis, Procardia, Cardizem, or other heart medications? Yes No
Dilantin or other medication for seizures? Yes No
Actonel, Didronel, Fosamax, Boniva or other Bisphosphonates? Yes No
Homeopathic medicines or herbal supplements? Yes No
Please list all medications, prescribed or over the counter, which you are currently taking:
Do you smoke? Yes No
Please check if you are allergic to any of the following:
Financial Arrangements and Insurance
We are committed to providing you with the best possible care. In order to achieve our goal, we need your assistance, and your understanding of our payment policy. Payment for services is due at the time services are rendered, unless payment arrangements have been approved in advance by our staff. We accept cash, checks, Visa and MasterCard. If you have dental insurance, we will be happy to help you process your insurance claim form for your reimbursement. You must realize, however, that: 1) Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. 2) Our fees are generally considered to fall within the acceptable range by most insurance companies, and therefore are covered up to a maximum allowance determined by each carrier. Some companies will only pay a percentage or the UCR (usual and customary and reasonable) fee for this region. 3) It has been our experience that Medicare does NOT cover any procedure that is done in the mouth. We must emphasize that as dental care providers, our relationship is with you, not the insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the service is rendered. We realize that temporary financial problems may effect timely payments of your account. If a problem does arise, please contact us promptly for assistance. Patient Signature _______________________________ Date ___________________


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