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Welcome |
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ABOUT YOU |
INSURANCE |
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Today's Date:
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Primary Insurance Dental Coverage? Yes No Medical Coverage? Yes No Insurance Co. Name: Insurance Co. Address: City: State: Zip: Group #: Insured's Last Name: First Name: Middle: Birth date: / / mm / dd / yyyy Social Security:-- Employer's Address: City: State: Zip: |
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Secondary Insurance |
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Insured's Last Name: First Name: Middle: Birth date: / / mm / dd / yyyy Social Security:-- Employer's Address: City: State: Zip: |
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SPOUSE INFORMATION |
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| Last Name: First Name: Middle: Birth date: / / mm / dd / yyyy Social Security: -- Home Phone #: -- Pager/Cell #: -- Work Phone #:-- Ext: Personal Email: Work Email: Employer: Previous/Present Dentist: |
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| I
affirm that the information I have given is correct to the best of my
knowledge. It will be held in the strictest confidence and it is my
responsibility to inform this office of any changes in my medical
status. I authorize the dental staff to perform will
be
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I
certify that I am covered by _______________________ Insurance company
and I assign directly to Dr. _________________________ all insurance
benefits, otherwise payable to me. I understand that I am responsible
for payment of services rendered and also responsible for paying any
co-payment and deductible that my insurance does not cover. I hereby
authorize the dentist to release all information necessary to secure the
payment of benefits. I authorize the use of this signature on all my
insurance submissions, whether manual or electronic.
Signature___________________________ Date:___________ |
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REFERRAL INFORMATION |
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| Whom may we thank for referring you to our
practice? Another patient- friend Another
patient-
relative Dental Office Yellow Pages Newspaper
School Work Internet Search Online dental
directory Online insurance dental directory Name of the person or office referring you to our practice? Other family members seen by us: |
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MEDICAL HISTORY |
DENTAL HISTORY |
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| Do
you have a personal physician? Yes
No Physician's Name: Phone #:-- Date of Last Visit: / / mm / dd / yyyy Your current physical health is: Good Fair Poor Are you currently under the care of a physician? Yes No Please explain: Do you smoke or use tobacco in any other form?Yes No Have you had any metal rods, pins or implants? Yes No |
Date of Last
Dental Visit:
/ /
mm / dd / yyyy Reason for this visit: Are you currently in pain? Yes No Do you require antibiotics before dental treatment? Yes No Your current dental health is: Good Fair Poor Have you ever had a serious/difficult problem associated with any previous dental work? Yes No Do you floss daily? Yes No Brush daily? Yes No Type of bristles on your toothbrush? Hard Medium Soft How long do you use a toothbrush before replacing it? Have you ever had gum treatment? Yes No Do your gum ever bleed? Yes No Ever Itch? Yes No Have you ever had periodontal disease? Yes No Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No Are your teeth sensitive to heat, cold, or anything else? YesNo Do you have mobility in your teeth? Yes No Do you still have any wisdom teeth? Yes No Would you like fresher breath? Whiter teeth? Yes No Are you happy with the way your smile looks? Yes No If not, what would you change? |
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| For
Women: Are you
taking birth control pills? Yes
No Are you pregnant? Yes No Week #: Are you nursing? Yes No |
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| Are you allergic to any of the following? | |||
| Aspirin Barbiturates Codeine Dental Anesthetics Erythromycin Jewelry/Metals |
Latex Penicillin Sedatives Sulfa Drugs Tetracycline Other |
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| List
additional drugs/materials that cause allergic reactions: |
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Are you taking any of the following? |
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| Acetaminophen Antibiotics Antihistamines Aspirin Blood Thinners Blood Pressure Medication Cold Remedies |
Digitalis/Heart Medication Insulin/Diabetes Drugs Nitroglycerin Recreational Drugs Steroids/Cortisone Thyroid Medicine Tranquilizers |
Are you taking any prescription/over-the-counter-drugs
not listed above? Yes
No
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Have you ever had any of the following diseases or medical problems? |
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| Abnormal Bleeding Alcohol Abuse Anemia Arthritis Artificial Bones/Joints Artificial Valves Asthma Blood Transfusion Cancer Chemotherapy Chicken Pox Colitis Congenital Heart Defect Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Fainting Spells |
Fever Blisters Glaucoma Hay Fever Headaches Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis Herpes High Blood Pressure HIV+/AIDS Hospitalized for Any Reason Kidney Problems Liver Disease Low Blood Pressure Lupus Mitral Value Prolapse Pacemaker |
Persistent Cough Psychiatric Problems Radiation Treatment Rheumatic Fever Scarlet Fever Seizures Shingles Sickle Cell Disease Sinus Problems Steroid Therapy Stroke Thyroid Problems Tonsillitis Tuberculosis (TB) Ulcers Venereal Disease |
Please list any serious medical condition (s) that you have experienced: |
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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 doctors at the next appointment without fail.
_______________________________________________________Date:_______________________ _______________________________________________________Date:_______________________ |
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