Today’s date ______ /______ /______ Mobile phone # ______________________________________________

Patient Name: Mr. Miss Mrs. Ms. Dr. Rev. Sr. Fr. _________________________________

Street Address ____________________________________________________________________________

City ____________________________________________ State _______________ ZIP _______________

Home phone # ___________________ Work phone # ___________________ Email _______________________

Date of birth ______ /______ /______ Soc. Sec. # ______ -______ -______ Referred by ____________________

Physician name & address _____________________________________________________________________

Place of employment & address __________________________________________________________________

Occupation _______________________________________________________________________________

Person to contact in case of emergency _____________________________ Phone # _________________________

Is another family member a patient here: Yes No Patient’s name ______________________________________

Authorization to confirm appointment _____________________________________________________________

( Patient Signature )

PatientInfo

Office Use Only

Name _______________________________ Nickname _______________________________ Age _______

Referred by _________________ How would you rate the condition of your mouth? Excellent Good Fair Poor

Previous Dentist ____________________ How long have you been a patient? ____________________ Months/Years

Date of most recent dental exam _____ /_____ /_____ Date of most recent x-rays _____ /_____ /_____

Date of most recent treatment (other than a cleaning) _____ /_____ /_____

I routinely see my dentist every: 3 months 4 months 6 months 12 months Not routinely

What is your immediate concern? ______________________________________________________________

Please answer yes or no to the following…

P E R S O N A L H I S T O R Y ● ● ●1.) Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [ ____ ] ________________ 2.) Have you had an unfavorable dental experience? _____________________________________________ 3.) Have you ever had complications from past dental treatment? ____________________________________ 4.) Have you ever had trouble getting numb or had any reactions to local anesthetic? _______________________ 5.) Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? ________________ 6.) Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?___

G U M & B O N E ● ● ●7.) Do your gums bleed or are they painful when brushing or flossing? _________________________________ 8.) Have you ever been treated for gum disease or been told you have lost bone around your teeth? ______________ 9.) Have you ever noticed an unpleasant taste or odor in your mouth? _________________________________ 10.) Is there anyone with a history of periodontal disease in your family? ________________________________ 11.) Have you ever experienced gum recession?_________________________________________________ 12.) Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? 13.) Have you experienced a burning or painful sensation in your mouth not related to your teeth? _______________

T O O T H S T R U C T U R E ● ● ●14.) Have you had any cavities within the past 3 years? ____________________________________________ 15.) Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? _________ 16.) Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? ___________________ 17.) Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? __________ 18.) Do you have grooves or notches on your teeth near the gum line? __________________________________ 19.) Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?________________________ 20.) Do you frequently get food caught between any teeth? _________________________________________

DentalHistoryPage 1 of 2

Continued on page 2…

YES NO

B I T E A N D J A W J O I N T ● ● ●21.) Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) ________________ 22.) Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? ___________ 23.) Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes,

protein bars, or other hard, dry foods? ___________________________________________________ 24.) In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? _______ 25.) Are your teeth becoming more crooked, crowded, or overlapped? __________________________________ 26.) Are your teeth developing spaces or becoming more loose? ______________________________________ 27.) Do you have trouble finding your bite, or need to squeeze, tap your teeth together,

or shift your jaw to make your teeth fit together? _____________________________________________ 28.) Do you place your tongue between your teeth or close your teeth against your tongue? ____________________ 29.) Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? _______________ 30.) Do you clench or grind your teeth together in the daytime or make them sore? _________________________ 31.) Do you have any problems with sleep (i.e. restlessness or teeth grinding),

wake up with a headache or an awareness of your teeth?________________________________________ 32.) Do you wear or have you ever worn a bite appliance? __________________________________________

S M I L E C H A R A C T E R I S T I C S ● ● ●33.) Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? _________ 34.) Have you ever whitened (bleached) your teeth? ______________________________________________ 35.) Have you felt uncomfortable or self conscious about the appearance of your teeth? ______________________ 36.) Have you been disappointed with the appearance of previous dental work?____________________________

Patient’s Signature _______________________________________ Date _____________________________

Doctor’s Signature _______________________________________ Date _____________________________

D O C T O R N O T E S :

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Dental HistoryPage 2 of 2

YES NO

Patient Name _____________________________ Nickname _____________________________ Age _______

Name of Physician/and their specialty _____________________________________________________________

Most recent physical examination ____________________________ Purpose ____________________________

What is your estimate of your general health? Excellent Good Fair Poor

Please answer yes or no to the following…

D O Y O U H AV E O R H AV E Y O U E V E R H A D :

1.) Hospitalization for illness or injury _______________________________________________________ 2.) An allergic or bad reaction to any of the following: _____________________________________________ Aspirin, Ibuprofen, Acetaminophen, Codeine Penicillin Erythromycin Tetracycline Sulfa

Local Anesthetic Fluoride Metals (nickel, gold, silver, ____________)

Latex Nuts Fruit Other______________________________________________

3.) Heart problems, or cardiac stent within the last six months _______________________________________ 4.) History of infective endocarditis_________________________________________________________ 5.) Artificial heart valve, repaired heart defect (PFO) _____________________________________________ 6.) Pacemaker or implantable defibrillator ____________________________________________________ 7.) Orthopedic implant (joint replacement) ____________________________________________________ 8.) Rheumatic or scarlet fever ____________________________________________________________ 9.) High or low blood pressure ____________________________________________________________ 10.) A stroke (taking blood thinners) _________________________________________________________ 11.) Anemia or other blood disorder _________________________________________________________ 12.) Prolonged bleeding due to a slight cut (INR > 3.5) ______________________________________________ 13.) Pneumonia, emphysema, shortness of breath, sarcoidosis ________________________________________ 14.) Tuberculosis, measles, chicken pox _______________________________________________________ 15.) Asthma _________________________________________________________________________ 16.) Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) ______________________________________ 17.) Kidney disease ____________________________________________________________________ 18.) Liver disease _____________________________________________________________________ 19.) Jaundice ________________________________________________________________________ 20.) Thyroid, parathyroid disease, or calcium deficiency ____________________________________________ 21.) Hormone deficiency _________________________________________________________________ 22.) High cholesterol or taking statin drugs_____________________________________________________ 23.) Diabetes (HbA1c = ) _________________________________________________________________ 24.) Stomach or duodenal ulcer ____________________________________________________________

MedicalHistoryPage 1 of 3

Continued on page 2…

YES NO

Continued on page 3…

25.) Digestive or eating disorders (e.g., Celiac Disease, Gastric Reflux, Bulimia, Anorexia) ______________________ 26.) Osteoporosis/Osteopenia (i.e. taking Bisphosphonates) _________________________________________ 27.) Arthritis ________________________________________________________________________ 28.) Autoimmune disease (i.e. Rheumatoid Arthritis, Lupus, Scleroderma) ________________________________ 29.) Glaucoma________________________________________________________________________ 30.) Contact lenses ____________________________________________________________________ 31.) Head or neck injuries ________________________________________________________________ 32.) Epilepsy, convulsions (seizures) _________________________________________________________ 33.) Neurologic disorders (ADD/ADHD, prion disease) _____________________________________________ 34.) Viral infections and cold sores __________________________________________________________ 35.) Any lumps or swelling in the mouth_______________________________________________________ 36.) Hives, skin rash, hay fever _____________________________________________________________ 37.) STI/STD/HPV ____________________________________________________________________ 38.) Hepatitis (type ) ___________________________________________________________________ 39.) HIV/AIDS _______________________________________________________________________ 40.) Tumor, abnormal growth _____________________________________________________________ 41.) Radiation therapy __________________________________________________________________ 42.) Chemotherapy, immunosuppressive medication_______________________________________________ 43.) Emotional difficulties ________________________________________________________________ 44.) Psychiatric treatment ________________________________________________________________ 45.) Antidepressant medication ____________________________________________________________ 46.) Alcohol/recreational drug use __________________________________________________________

A R E Y O U :

47.) Presently being treated for any other illness _________________________________________________ 48.) Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)________________ 49.) Taking medication for weight management __________________________________________________ 50.) Taking dietary supplements ____________________________________________________________ 51.) Often exhausted or fatigued ____________________________________________________________ 52.) Experiencing frequent headaches ________________________________________________________ 53.) A smoker, smoked previously or use smokeless tobacco _________________________________________ 54.) Considered a touchy/sensitive person _____________________________________________________ 55.) Often unhappy or depressed ___________________________________________________________ 56.) Taking birth control pills______________________________________________________________ 57.) Currently pregnant _________________________________________________________________ 58.) Diagnosed with a prostate disorder _______________________________________________________

Medical HistoryPage 2 of 3

YES NO

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly

affect your dental treatment. (i.e. Botox, Collagen Injections):

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

List all medications, supplements, and or vitamins taken within the last two years.

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Drug _____________________________ Purpose _______________________________________________

Please advise us in the future of any change in your medical history or any medications you may be taking.

Patient’s Signature _______________________________________ Date _____________________________

Doctor’s Signature _______________________________________ Date _____________________________

A S A ( 1 – 6 ) ● ● ●

Medical HistoryPage 3 of 3

PAY M E N T / I N S U R A N C E B E N E F I T SThank you for choosing our office as your dental health care provider. We are committed

to providing you with the highest quality dental care, so that you may attain optimum oral

health. Please understand that payment of your bill is considered part of your treatment.

The following is a statement of our financial policy, which we require that you read, agree

to, and sign prior to any treatment.

Payment is due at the time service is provided. Our office accepts cash, personal checks,

VISA, MasterCard, Discover, American Express and offers Care Credit and Lending Club.

Insurance benefits are determined by your employer and not your dentist. Insurance is not

a guarantee of payment and they most often will not pay for all of your dental needs. Your

insurance policy is a contract between you and your employer. As a courtesy, our office will

electronically submit insurance claims on your behalf. We will need the proper insurance

information to be able to process the claim. You are responsible for payment at the time of

service. The reimbursement will then be issued directly to you from your insurance company.

All charges you incur are your responsibility regardless of your insurance benefits. We

will cooperate fully with the regulations and requests of your insurance company that may

assist in the claim being paid. Our office will, if needed, assist you in any disputes with

your insurance company over any claim. If problems arise in getting a claim paid, specific

questions should be directed to your insurance carrier or your employer.

I HAVE READ, UNDERSTAND AND AGREE TO THE AB OVE TERMS AND

CONDITIONS REGARDING THE FINANCIAL AND APPOINTMENT POLICY

FOR THIS PRACTICE.

_____________________________

Printed Name

_____________________________

Patient / Guarantor Signature

_____________________________

Date

_____________________________

Office Administrator Signature

_____________________________

Date

Policy:Financial

C A N C E L L AT I O N / R E S C H E D U L I N GWe respect the importance of your time and we work very hard to schedule appointments

that accommodate the scheduling needs of all of our patients. We want you to know that we

make every effort to see you at your scheduled appointment time. We feel that a successful

outcome to treatment is the result of combined efforts of both you and this office. Therefore,

it is important to adhere to the recommended treatment schedule to obtain optimum results.

If you must cancel or reschedule an appointment, we would greatly appreciate that you notify

us at least two business days prior to your scheduled appointment time. Broken, missed

appointments, as well as late arrivals create scheduling problems for other patients as well

as the practice. Appointments are considered reservations and you will receive a reminder

email/text or call prior to this appointment. If we are unable to reach you, we trust that you

will keep your reserved appointment. Repeated late cancellations or rescheduling will force

us to double book your appointment or to institute a fee for a missed appointment. We ask for

your careful consideration regarding this matter. In return, we promise to provide you with

the very best dental care.

I HAVE READ, UNDERSTAND AND AGREE TO THE AB OVE TERMS AND

CONDITIONS REGARDING THE FINANCIAL AND APPOINTMENT POLICY

FOR THIS PRACTICE.

Policy:Appointments

_____________________________

Printed Name

_____________________________

Patient / Guarantor Signature

_____________________________

Date

_____________________________

Office Administrator Signature

_____________________________

Date

CancellationsPolicy:

4 8 H O U R N O T I C E / F E E SMaplewood Dental Associates has a 48 hour cancellation/rescheduling policy.

If you miss your appointment, cancel or change your appointment with less than

48 hours notice, you will be charged $35.

This policy is in place out of respect for our doctors and hygienists. Cancellations with less

than 48 hours notice are difficult to fill. By giving last minute notice or no notice at all, you

prevent someone else from being able to schedule into that time slot.

By signing below, you acknowledge that you have read and understand the Cancellation Policy

for Maplewood Dental Associates as described above.

Thank you for your understanding and cooperation.

_____________________________

Printed Name

_____________________________

Patient / Guarantor Signature

_____________________________

Date

hipaaPolicy:

H I PA A A C K N O W L E D G M E N T O F R E C E I P TO F N O T I C E O F P R I VA C Y P O L I C I E SYour privacy is important to us. I hereby authorize, Maplewood Dental Associates as

indicated by my signature below, Maplewood Dental Associates to use and to disclose my

protected health information for any necessary clinical, financial, and insurance purpose,

as authorized in the Patient Consent form.

You may contact me at my home telephone number

You may contact me on my mobile telephone number

You may contact me on my work telephone number

You may send me an email

Other ____________________________________________________

Please check if you would like a copy of our privacy policies to be mailed/given to you

Please list authorized persons with whom we may discuss your Protected Health

Information (PHI) in addition to custodial parents and legal guardians:

( Example: John Doe, 212-555-1212 )

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

_________________________________________ ______________

Patient / Guarantor Signature Date

For Office Use Only:

We attempted to obtain

written acknowledgement

of receipt of our Notice of

Privacy Practices, but

acknowledgement could not

be obtained because:

Individual refused to sign

Communication barriers

prohibited obtaining the

acknowledgement

An emergency situation

prevented us from obtain-

ing the acknowledgement

Other ( please specify )

__________________

__________________

__________________

__________________

__________________

__________________