First Name Last Name Middle Name
Physical Address Home Phone Work/Cell Phone
City State Zip Code
Email Address Best Time and Place to Reach You
Sex M/F Age Birthdate Single/Married/Divorced
Patient Social Security Number Occupation Employer
Employer Address Employer Phone Number Spouse Name Birthdate Social Security
Occupation Spouse's Employer
_______________________________________________________________________________________
Whom may we tank for referring you? Who is responsible for this account? Relationship to patient
Insurance Company Group# Is patient covered by additional insurance? yes/no Subscriber's Name Subscriber's Birthdate Subscriber's SS# Relationship to patient Insurance Company Group#
Assignment and Release I, the undersigned cetify that I (or my dependent) have insurance coverage with and assign directly to doctor otherwise payable to me for servieces rendered. I understang that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature Relationship Date
Dental History
Reason for today's visit Former Dentist City/State Date of last dental visit Date of last dental x-ray Please check to indicate you have had any of the following:
Bleeding gums Chew on one side of mouth Jaw pain Food collection between teeth Difficulty w/ previous dental work Gums swollen Loose teeth or broken fillings Cigarette, pipe, cigar smoking Jaw tiredness or tightness Type of bristle Hard/Medium/Soft How often do you brush?
Blisters on lips or mouth Mouth breathing Fingernal biting Chewing tobacco Grinding teeth Orthodontics Do you like your smile Sensitive to sweets Sensitive to heat Problems getting numb
Medical History
Physicain's Name Date of last visit
Please check to indicate you have had any of the following:
AIDS Anemia Arthritis, Rheumatism Artificail Heart Valves Artificial Joints Asthma Back Problems Bleeding Abnormally Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Congenital Heart Cortisone Treatments Cough, persistent/bloddy Diabetes Contacts Epilepsy Fainting or Dizziness Glaucoma
Headaches Heart Murmur Heart Problems Hepatitis Herpes High Blood Pressure Meds HIV Positive Jaundice Jaw Pain Joint Replacement Kidney Disease Lesion Liver Disease Low Blood Pressure Mitral Valve Prolapse Nervous Problems Pace Maker Pregnant Due date Nursing Birth control pills
Psychiatric Care Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Sinus Trouble Skin Rash Special Diet Stroke Swelling of Feet or Ankles Swollen Neck Glands Thyroid Problems Tonsillitis Tuberculosis Tumor or Growth Ulcer Venereal Disease Weight Loss, unexplained Hospital Stays
List of Medications
Allergies to Medicines:
Amoxicillin Aspirin Barbiturates
Codeine Epinephrine Erythromycin
Keflex Iodine Latex
Loratab Morphine Penicillin
Sulfa Tetracycline Other
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement 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 patients 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. A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore 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. 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.
