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AIDS |
Excessive Bleeding |
Liver Disease |
Stroke |
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Allergies |
Fainting |
Mental Disorders |
Tuberculosis |
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Glaucoma |
Nervous Disorders |
Tumors |
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Anemia |
Growths |
Pacemaker |
Ulcers |
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Arthritis |
Hay Fever |
Pregnancy |
Venereal Disease |
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Artificial Joints |
Head Injuries |
Due date: |
Codeine Allergy |
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Asthma |
Heart Disease |
Radiation Treatment |
Penicillin Allergy |
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Blood Disease |
Heart Murmur |
Respiratory Problems |
OTHER: |
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Cancer |
Hepatitis |
Rheumatic Fever |
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Diabetes |
High Blood Pressure |
Rheumatism |
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Dizziness |
Jaundice |
Sinus Problems |
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Epilepsy |
Kidney Disease |
Stomach Problems |
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Have you ever had any complications following dental treatment? Yes No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
If yes, please explain:
Are you now under the care of a physician? Yes No
If yes, please explain:
Name of Physician: Phone:
Do you have any health problems that need further clarification? Yes No
If yes, please explain:
Are you taking any medications? Please list
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment.
Date:
Signature of patient, parent or guardian
Date:
Signature of Doctor
Cosmetic Information
Is there anything about your smile that you do not like?
Are you interested in knowing the options available for a more beautiful smile?
Do you like the appearance of your teeth?
Are all of your teeth in alignment (straight)?
Do you have any missing teeth? Are any chipped?
Is your bite comfortable when chewing, biting?
Do you have frequent headaches?
Do you have any old fillings or dental treatment that you are unhappy with?
What would you like to change the most about the appearance of your teeth?
Is there anything else that you would like us to know?
Referral Information
Whom may we thank for referring you to our practice?
Another patient Friend Another Doctor School Work Other
Name of person or office referring you to our practice:
Spouse or Responsible Party Information
The following is for: the patient's spouse the person responsible for payment
Last Name: First Name: Middle Initial:
Male Female Married Single Other
Social Security #: Date of Birth: Driver’s License #:
Phone (Home): (Work): Ext: Best time to call:
Street Address: Apartment #:
City: State: Zip Code:
Employment Information
The following is for: the patient the person responsible for payment
Employer Name: Occupation:
Street Address: City: State: Zip Code:
Insurance Information
Last Name of Insured: First Name: Middle Initial:
Is insured a patient? Yes No
Insured's Date of Birth: Social Security #: Group #:
Insured's Address: City: State: Zip Code:
Insured's Employer Name:
Street Address: City: State: Zip Code:
Patient's relationship to insured: Self Spouse Child Other
Insurance Plan Name: Telephone:
Consent for Services
(Required)
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon payment from the patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections 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.
In consideration for the professional services rendered to me or at my request, by the Doctor, I agree to pay the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
Further, I understand and acknowledge that photographs and images of me may be shown to other patients and doctors for treatment and educational purposes and I agree to the same.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content.
Date: Relationship to Patient:
Signature of patient, parent or guardian
Date: Relationship to Patient:
Signature of guarantor of payment/responsible party