PATIENT INFORMATION

Name: Birth date

Address: City Zip Code

Home Phone:    Cell Phone:

Email:

Driver’s License #      SSN:

Check which applies:   Single   Married  Divorced    Separated   

RESPONSIBLE PARTY INFORMATION (Please fill out if different from above)

Spouse or Parent/Guardian Name :

Relationship to Patient?

Who should we contact in case of emergency?
Number to contact:

Whom may we thank for referring you?

DENTAL INSURANCE INFORMATION
Name of Insured Birth Date
Employer
Relationship to Patient   Insurance Comp
Insurance Phone Insurance ID# or SSN
Group #

SECONDARY DENTAL INSURANCE INFORMATION (if applicable)
Name of Insured Birth Date Employer
Relationship to Patient Insurance Comp
Insurance Phone Insurance ID# or SSN   Group


MEDICAL INFORMATION

  1. Are you under the care of a physician?   Yes    No
  2. Have you ever been hospitalized or had a major operation?   Yes    No

       If yes, what?

  1. Ever had a head or neck injury?  Yes    No
  2. Are you taking any medications, pills or drugs? Yes    No

        If yes please list

  1. Have you ever taken fosomax? Yes    No
  2. Do you take or have you taken, Phen Fen or Redux?  Yes    No
  3. Are you on a special diet?    Yes    No
  4. Do you use tobacco? Yes ____No____Do you use controlled substances?   Yes    No
  5. Please check any of the following that you are allergic to?

Aspirin      Penicillin     Sulfa     Codeine   Acrylic  Metal      Latex      Local Anesthetic
Other allergies not listed above:

WOMEN
:   Are you taking oral contraceptives?   Yes    No       Are you pregnant? Yes    No

Please check any conditions you currently have or have had :

AIDS/ HIV Positive Cold Sores    Glaucoma  Irregular Heartbeat Scarlet Fever
Alzheimer’s Disease     Congenital Heart Disorder Hay Fever Kidney Problems Shingles
Anaphlylaxis   Convulsions Heart Attack/Failure Leukemia Sickle Cell Disease
Anemia Cortisone Meds Heart Murmur Liver Disease Sinus Trouble
Angina      Diabetes Heart Pace Maker Low Blood Pressure Spina Bifida
Arthritis   Drug Addiction Heart Trouble/Disease Lung Disease Stomach/Intestinal Problems
Artificial Heart Valves Easily Winded Hemophilia Mitral Valve Prolapse Stroke
Artificial Joints Emphysema   Hepatitis A Pain in Jaw Joints Swelling of LImbs
Asthma    Epilepsy /Seizures Hepatitis B Parathyroid Disease Thyroid Disease
Blood Disease   Excessive Bleeding Hepatitis C Psyciatric Care Tonsillitis
Blood Transfusion Excessive Thirst Herpes Radiation Treatment Tuberculosis
Breathing Problems Fainting /Dizziness High Blood Pressure Recent Weight Loss Tumors/Growths
Bruise Easily   Frequent Cough High Cholesterol Renal Dialysis Ulcers
Cancer  Frequent Diarrhea Hives or Rash Rheumatic Fever Venereal Disease
Chemotherapy Frequent Headaches Hypoglycemia Rheumatism Yellow Jaundice
Chest Pains        

Have you ever had any serious illness not listed above?  

Patient Signature ________________________________   Date:

FAMILY HISTORY
Please check yes/no next to each listed condition to indicate if anyone in your immediate family (parents or siblings) have or have had it.
If they have, please indicate the person's relationship to you.  i.e. mother

Heart Disease
Diabetes     
Periodontal (Gum) Disease     
Alzheimer’s Disease     
High Blood Pressure     
Pancreatic and or Kidney Cancer       
Stroke      
Head or neck cancer      

DENTAL HISTORY
How would you rate the condition of your mouth?       Excellent        Good        Fair     Poor
Previous Dentist How long were you a patient?
Date of most recent dental exam  Date of most recent xrays 
Date of most recent treatment (other than a cleaning)  
I routinely see my dentist every      3mos.   4 mos.    6 mos.   12 mos.  Not routinely
What is your immediate concern?
PERSONAL HISTORY  SELECT YES  NO
1.  Are you fearful of dental treatment? How fearful on a scale of 1 (least) 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?
6.   Have you had any teeth removed or missing teeth that never developed?
7.   Do your gums bleed or are they painful when brushing or flossing? 
GUM AND BONE   SELECT YES  NO
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 had any teeth become loose on their own (without injury) or do you have difficulty eating apples?
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
TOOTH STRUCTURE SELECT YES  NO
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 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 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 your teeth?
BITE AND JAW JOINT SELECT YES  NO
21. Do you have problems with your jaw joint?
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, protein bars or other hard, dry foods?
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
25. Are your teeth becoming more crooked, crowded, or overlapped?
26. Are your teeth developing spaces or becoming looser?<
27. Do you have more than one bite or do you squeeze or shift your jaw to make your teeth fit?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, hold objects in your teeth or have any other oral habits?
30. Do you clench your teeth in the daytime or make them sore?
31. Do you have any problems with sleep or wake up with an awareness of your teeth?
32. Do you wear or have ever worn a bite splint?
SMILE CHARACTERISTICS  SELECT YES  NO
33. Is there anything about the appearance of your teeth that you would like to change?
34. Have you ever whitened (bleached) your teeth?
35. Have you felt uncomfortable or self consious about the appearance of your teeth?
36. Have you been disappointed with the appearance of previous dental work?

INSURANCE INFORMATION

To our patients with insurance:
Please remember that your insurance coverage is a contract between you and your insurance company and is not a substitute for payment. If you would like a more accurate estimate of what your dollar portion will be for proposed treatment, we would encourage you to contact your insurance company for that benefit information. We will gladly submit your claim to your insurance company, but your portion is due the day of treatment. After receiving payment from your insurance company, you will then receive a bill from our office if there is any remaining balance. Payment is required within 15 days of notification.

To our patients without insurance:
We request that all charges be paid at the time of each visit.

**A $3.00 billing fee will be added to your balance if statements are sent out. If the account becomes past due and turned over to collections, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collections efforts.  Your account being turned over to collections may result in you and anyone associated with this account being dismissed from the practice.

I understand and agree to the above policy:   

 Signature of Patient/Parent or Legal Guardian                              

HIPAA PRIVACY FORM

HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization.  In refusing we may not be allowed to process your insurance claims.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility.   A copy of this signed, dated document shall be as effective as the original. 
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITYS IN THE FUTURE.
           
DATE :

PLEASE PRINT YOUR NAME:           PLEASE SIGN YOUR NAME:

LEGAL REPRESENTATIVE:       DESCRIPTION OF AUTHORITY:

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA?
First Name Only   Proper Sir Name    Other

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name:   Relationship  

Name:   Relationship