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Westminsterfamilydentist.com

Mountain Range Dentistry
PATIENT INFORMATION
PATIENT’S NAME
LAST______________________________FIRST______________________________MI_____DATE ___________
GENDER (M) (F)_____AGE___________BIRTHDATE__________________ DRIVER’S LICENSE NUMBER_____________________
ADDRESS______________________________________________CITY__________________________STATE__________ZIP__________
PARENT/GUARDIAN’S NAME (IF MINOR) ____________________________________________________________________________
EMPLOYER ________________________________________________OCCUPATION___________________________________________
REFERRED BY ______________________________________
RESPONSIBLE PARTY (IF DIFFERENT FROM ABOVE)
NAME LAST______________________________FIRST______________________________MI_____
ADDRESS______________________________________________CITY__________________________STATE__________ZIP___________
HOME PHONE _________________________WORK PHONE_________________________CELL PHONE__________________________
EMPLOYER ________________________________________________OCCUPATION____________________________________________
RELATIONSHIP TO PATIENT_______________________________________
DENTAL INSURANCE INFORMATION
DO YOU HAVE DUAL COVERAGE? Y/N_____
SUBSCRIBER NAME__________________________________________________________ EMPLOYER___________________________
BIRTHDATE___________________ SOCIAL SECURITY #/ID #_________________________
INSURANCE COMPANY ____________________________________GROUP/PLAN NO._______________________________________
SECONDARY
SUBSCRIBER NAME__________________________________________________________ EMPLOYER___________________________
BIRTHDATE___________________ SOCIAL SECURITY #/ID #_________________________
INSURANCE COMPANY ____________________________________GROUP/PLAN NO._______________________________________
PHONE NUMBERS AND CONTACTS
HOME PHONE _________________________WORK PHONE_________________________CELL PHONE__________________________
BEST NUMBER TO BE CONTACTED:____________________________E-MAIL _______________________________________________
EMERGENCY CONTACT
NAME __________________________________________________________RELATIONSHIP _____________________________________
BEST NUMBER TO REACH YOUR CONTACT IN THE EVENT OF AN EMERGENCY________________________________________
Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S.
1005 West 120th Avenue, Suite 800
Westminster, Colorado 80234
303-452-2221
Mountain Range Dentistry
DENTAL/HEALTH HISTORY
Reason for today’s visit____________________________________________________________________________________________
Former Dentist_________________________

City/State_________________________ Date of last visit___________________
Date of last dental x-rays_____________________
Any PRE-MEDICATION needed?__________________
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Bad breath

Yes No
Bleeding gums
Yes No Blisters on lips/mouth
Yes No
Dry mouth
Yes No
Fingernail biting
Yes No Chew on one side of mouth
Yes No
Grinding teeth
Yes No
Swollen gums
Yes No Burning sensation on tongue
Yes No
Yes No
Sensitivity to heat
Yes No Food collection between teeth
Yes No
Piercing
Yes No
Sensitivity to cold
Yes No Loose teeth or broken fillings
Yes No
Sensitivity when bitingYes No
Sensitivity to sweets
Yes No Sores/growths in your mouth
Yes No
Jaw pain/clicking
Yes No
Mouth pain, brushing Yes No Periodontal treatment
Yes No
Tobacco use
Yes No
Mouth breathing Yes No Orthodontic treatment
Yes No
HEALTH HISTORY
Have you EVER taken any of the group of OSTEOPOROSIS drugs collectively referred to as “bisphosphonates”? These are used to
increase bone density. These include, but are not limited to, oral forms such as Actonel (risedronate), Boniva (ibandronate),
Fosamax/ Plus D (alendronate), Skelid (tiludronate), Didronel (etidronate), or I.V. forms such as Aredia (pamidronate), Zometa
(zolendronic acid), Bonefos (clodronate).
Place a mark on “yes” or “no” to indicate if you have had any of the following:AIDS/HIV Women:
Are you taking birth control pills? Yes No MEDICATIONS, VITAMINS, AND SUPPLEMENTS
ALLERGIES
List any medications, vitamins, and supplements you are Please list any allergies you have especially any drug currently taking and the correlating diagnosis: _____________________________________________________ __________________________________________________ _____________________________________________________ __________________________________________________ _____________________________________________________ __________________________________________________ _____________________________________________________ __________________________________________________ Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S.
1005 West 120th Avenue, Suite 800
Westminster, Colorado 80234
303-452-2221
Mountain Range Dentistry
INFORMED CONSENT
The undersigned hereby authorizes the Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctorto make a thorough diagnosis of the patient’s dental needs. I authorize Doctor to perform any and all forms of treatment, medication, and therapy thatmay be indicated. I understand that the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between meand the insurance carrier, and not between the insurance carrier and the Doctor and that I am fully responsible for all dental fees. These fees are due andpayable at the time that services are rendered unless prior financial arrangements have been made. I also agree to assign all insurance benefits to theDoctor for services rendered. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if Ihave paid the dental fees incurred. I further understand that a late charge may be applied to my account for any overdue balance.
Patient/guardian signature_________________________________________
Dentist signature
Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S.
1005 West 120th Avenue, Suite 800
Westminster, Colorado 80234
303-452-2221

Source: http://westminsterfamilydentist.com/wp-content/uploads/2013/06/New-Patient-Form-final-website.pdf

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