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PATIENT INFORMATION

PATIENT LAST NAME:
FIRST NAME:
DATE OF BIRTH:
MALE
FEMALE
CELL PHONE
WORK PHONE
EXT:
HOME PHONE
EMAIL ADDRESS
ADDRESS
WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
PHYSICIAN’S Name:
PHONE #

HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CIRCLE THOSE THAT APPLY:

AIDS/HIV POSITIVE
DIABETES
ANEMIA
EPILEPSY
ARTHRITIS/RHEUMATISM
FAINTING/DIZZINESS
ARTIFICIAL JOINTS
GLAUCOMOA
ASHTMA
HEADACHES
BLOOD DISEASE
HEART MURMUR
CANCER/CHEMOTHERAPY
HEART PROBLEMS
CHEMICAL DEPENDENCY
DESCRIBE:
CIRCULATORY PROBLEMS
HEPATITIS
CORTISONE TREATMENT
HPV
KIDNEY DISEASE
SINUS PROBLEMS
LIVER DISEASE
SMOKE/CHEW
MITRAL VALVE PROLAPSE
STROKE
MENTAL DISORDERS
THYROID PROBLEMS
NERVOUS DISORDERS
TUBERCULOSIS
OSTEOPOROSIS
TUMOR
PACEMAKER
ULCERS
PREGNANCY
VENEREAL DISEASE
RADIATION TREATMENT
ALLERGIES:
RESPIRATORY PROBLEMS
RHEUMATIC FEVER
SHORTNESS OF BREATH
PLEASE LIST MEDICATIONS YOU ARE NOW TAKING:
EMERGENCY CONTACT NAME:
PHONE #

DO YOU HAVE ANY HEALTH PROBLEMS THAT NEED FURTHER CLARIFICATION :

Yes
No
IF YES PLEASE EXPLAIN:
PATIENT INFORMATION

REASON FOR TODAYS VISIT:
DATE OF LAST CHECKUP/XRAYS
FORMER DENTIST
PHONE#

HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CIRCLE THOSE THAT APPLY:

BAD BREATH
PERIODONTAL TREATMENT
BLEEDING GUMS
SENSITIVITY TO COLD/HOT
CLICKING OR POPPING JAW
JAW PAIN
FOOD COLLECTION BETWEEN TEETH
SNORING
SORES OR GROWTH IN YOUR MOUTH
SENSITIVITY TO SWEETS
GRINDING TEETH
SENSITIVITY WHEN BITING
LOOSE OR BROKEN TEETH
HOW OFTEN DO YOU FLOSS?
HOW OFTEN DO YOU BRUSH?
ARE YOU FREARFUL OF DENTAL TREATMENT?
IS THERE ANYTHING YOU WOULD LIKE TO CHANGE ABOUT THE APPEARANCE/COLOR OF YOUR TEETH OR SMILE?
IS THERE ANYTHING YOU WOULD LIKE TO CHANGE ABOUT THE APPEARANCE/COLOR OF YOUR TEETH OR SMILE?

FOR FEMALES ONLY: PLEASE NOTIFY IF YOU ARE BREAST FEEDING:

Yes
No
CONSENT FOR SERVICES AND FINANCIAL POLICY

WE ARE COMMITTED TO YOUR DENTAL CARE BEING SUCCESSFUL. PLEASE UDNERSTAND THAT PAYMENT FOR YOUR CARE IS CONSIDERED PART OF THAT CARE. PLEASE READ THE FOLLOWING INFORMATIONC AREFULLY. WE ASK THAT YOU READ AGREE TO AND SIGN PRIOR TO ANY TREATMENT

– ALL PATIENTS MUST COMPLETE OUR PATIENT INFORMATION FORM BEFORE RECEIVING TREATMENT

– FULL PAYMENT IS DUE AT THE TIME OF SERVICE UNLESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE

– PATIENTS WHO CARRY DENTAL INSURANCE UNDERSTAND THAT ALL DENTAL SERVICES FURNISHED ARE CHARGED DIRECTY TO THE PATIENT’S ACCOUNT. WE WILL COMPLETE THE PATIENTS INSURANCE FORMS OR ASSIST IN MAKING COLLECTION FROM INSURANCE COMPANIES AND WILL CREDIT ANY SUCH COLLECTIONS TO THE PATIENT’S ACCOUNT. HOWEVER THIS DENTAL OFFICE CANNOT RENDER SERVICES ON THE ASSUMPTION THAT OUR CHARGES WILL BE PAID BY AN INSURANCE COMPANY

– ESTIMATED CO-PAY AND DEDUCTIBLE IS DUE AT THE TIME OF SERVICE

– WE ACCEPT CASH, VISA, MASTERCARD AND DEBIT

– THERE WILL BE A CHARGE FOR APPOINTMENTS MISSED WITHOUT 2 BUSINESS DAYS NOTICE

PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THIS INFORMATION.

I HAVE READ THE ABOVE CONDITIONS OF TREATMENT AND PAYMENT AND AGREE TO THEIR CONTENT.

RELATIONSHIP TO PATIENT

SIGNATURE OF PATIENT/PARENT OR GUARDIAN

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