patierut lnformatian - prosites
TRANSCRIPT
We are pleased to welcome yoa to our practice.
'l - completely r$ yoa can. Ifyou haue questions wdll be
glad to help you. We looh foryord to uorbing uith lou,iyrnaintain ng yoar dcntal heahh.
Please tahe a few minutes to fill oat tbis fotm as
Phone ( ) Alt. Phone ( )
SS/HlC/Patient lD #Middle lnitial
State
-
Zip
n Widowed [l Single I Minor! Divorced fl Partnered for
-
years
Employer/School Phone (-)
Whom may we thank for referring you?
Patierut lnformatian
Last Name
Address
City
SexlM nF Age-Bi I Marriedfl Seoarated
OccupationPatient Employer/School
Employer/School Address
ln case of emergency who should be notified ? Phone ( )
Primary lnsurd,ncePerson Responsible for Account
Last Name First Name Middle lnitial
Relation to Patient
Address (lf different from patient's)
Birthdate Soc. Sec. #
Phone ( )
State _ Zip
Person Responsible Employed by Occupation
Business Phone ( )
City
Business Address
lnsurance Company
Contract #
Names of other dependents covered under this plan
Subscriber Name
Address (lf different from patient's)
Group # Subscriber #
fl No
Birthdate Relation to Patient
Phone ( )
State
--
Zip
Subscriber Employed by Business Phone ( )
lnsurance Company
Contract #
Soc. Sec. #
Group #
Names of other dependents covered under this plan
Additional lnsararrcels patient covered by additional insurancel I Yes
City
Rev.3/2012 Please Complete Both Sides
Subscriber #
#2 1 786 - Ol\.4edical Arts Press 1 -800-328 -217 I
Check ( / ) if you have had problems with any of the following:
E Bad breath n Grinding teeth [1 Sensitivity to hot
! Bleeding gums [] Loose teeth or broken fillings I Sensitiviry to sweets
[] Clicking or popping law I Periodonal treatment I Sensitivity when biting
I Food collection between teeth E Sensitivity to cold I Sores or growths in your mouth
Dental HistoryReason for Today's Visit Date of last dental care
Former Dentist Date of last dental X-rays
How often do you floss? How often do you brush?
Medical HistoryPhysicianl Name Date of LastVisit
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. IYes E tto
Have you ever taken any of the group of drugs collectively referred to as 'fen-phen?" These include combinations of lonimin, Adipex, Fastin
(brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). EYes n No
Have you had any serious illnesses or operations? [Yes I No lf yes,describe
Have you ever had a blood transfusionl nYes I No lf yes,give approximate dates
(Women)Are you pregnantl EYes E No Nursing? IYes I No Taking birth control pills? IYes E No
Check ( / 1lt you have or have had any of the following:
EAnemia E Cortisone Treatments ! Hepatitis n Scarlet Fever
EArthritis, Rheumatism n Cough, Persistent n Higl-r Blood Pressure E Shortness of Breath
nArtificial HeartValves I Cough up Blood n HIViAIDS
I Artificial Joints
n Asthma
I Back Problems
n Blood Disease
n Cancer
tr Diabetes
! Epilepsy
I Fainting
I Glaucoma
n Headaches
n Jaw Pain
[f Kidney Disease
T Liver Disease
E Skin Rash
n Stroke
[1 Swelling of Feet orAnkles
I Thyroid Problems
I Chemical Dependency E Heart Murmur
n Chemotherapy [] Heart Problems
I Circulatory Problems [1 Hemophilia
MEDICATIONS: List medications you are currently taking:
n Mitral Valve Prolapse trTobacco Habit
E Pacemaker J Tonsillitis
X Radiation Treatment n Tuberculosis
I Respiratory Disease n Ulcer
I Rheumatic Fever nVenereal Disease
ALLERGIES
AuthorizationI certify that l, and/or my dependent(s), have insurance coverage with
Name of lnsurance Company(ies)and assign directly to \i
all insurance benefits, if any, otherwise payable to me for services rendered. I understandthat I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance
submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named lnsurance Company(ies)
and their agents for the purpose of obtaining paymenr for services and determining insurance benefits or the benefits payable for related
services.This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative
Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient
Payment is due in full at time of treatment unless prior arrangements have been aPProved.