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Patient Name *
Patient Name
Sex
Home Address
Home Address
Home Phone *
Home Phone
Business Phone
Business Phone
Student
Work Status
Spouse's Name
Spouse's Name
Insurance Information
xrays
Have you had a full mouth set of xrays or a panorex within the past three (3) years?
Fill in this portion only of patient is covered by parent(s) insurance or is a minor
Father's Address
Father's Address
Business Phone
Business Phone
Mother's Address
Mother's Address
Business Phone
Business Phone
Fees and Payment
We make every effort to keep down the cost of your oral surgical care. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It s your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorney’s fees, and court costs.
Medical history
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential.
1.
Has there been any change in your health in the past year?
2.
Are you now under the care of a physician?
The name, address, and phone # of my physician is
4.
Have you had a serious illness, significant operation or been hospitalized within the past 5 years?
5.
Are you taking any medication(s)?
6.
Do you have or have you had any of the following diseases or problems?
a.
Damaged or artificial heart valves, rheumatic heart disease or heart murmur
b.
Heart failure, heart attack angina, high blood pressure, stroke, or any other cardiac condition
c.
Fainting spells, seizures, epilepsy, or neurological disorder
d.
Diabetes or thyroid problems
e.
Hepatitis, jaundice or liver disease
f.
Respiratory problems, asthma, emphysema, bronchitis or chronic cough
g.
Arthritis or painful swollen joints including your jaw joint (TMJ)
h.
Stomach ulcer or reflux
i.
Kidney trouble
j.
Tuberculosis
k.
Are you taking vitamins, homeopathic remedies, or diet pills
7.
Have you had abnormal bleeding or been diagnosed with any type of anemia?
a.
Have you ever required a blood transfusion?
8.
Are you allergic to or have you had a reaction to:
a.
Local anesthetics
b.
Penicillin, sulfa drugs or other antibiotics
b.
Aspirin
c.
Iodine
d.
Codeine or other narcotics
e.
Latex or rubber products
f.
Other Medications
9.
Have you had any serious trouble associated with previous dental treatment?
10.
Do you smoke?
11.
Do you have any other conditions or disease you think the doctor should know about?
12.
Are you wearing contact lenses?
13.
Are you wearing removable dental appliances?
14.
Do you wish to talk with the doctor privately about anything?
Women
15.
Are you pregnant or trying to become pregnant?
16.
Are you nursing?
17.
Are you taking birth control pills?
Chief Dental Complaint or Purpose of Consultation:
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any member of the staff responsible for any errors or omissions that I may have made in the completion of the form.
Date
Date
Inputting your name represents an electronic signing of this document