Date :

SS/HIC/Patient ID :

Patient Name :

Email :

Address :

City :

State :

Zip Code :

Sex : Male Female

Age :

Birthdate : (mm/dd/yy)

Married Widowed Single Minor Separeted Divorced Partnerd for Years

Patient Employer/School :

Occupation :

Employer School Address :

Employer School Phone :

Birth Date :

SS :

Spouse's Employer :

Who is responsible for this account?

Relationship to patient :

Insurance Company :

Group :

Is patient covered by additional insurance? Yes No

Subscriber's Name :

Birth Date :

SS :

Relationship to patient :

Insurance Company :

Group :

Assignment and Release

I certify that i and/or my dependents(s) have insurance coverge with provided insurance company and assign directly to Doctor all insurance benefits. If any otherwise payable to me for services rendered. I understand that i am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named dentist may use my health care information and many disclose such information to the above named insurance company(ies) and thier agents for the purpose of obtaining payment for services and determining insurance benefits or the patients payabale for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Home :

Work :

Spouse's Work :

Best time and place to reach you :

In Case of EMERGENCY Contact (Specify someone who does not live in your household)

Name :

Relationship :

Home Phone:

Work Phone:

Reason for today visit :

Former Dentist :

City/State :

Date of last dental visit :

Date of Last Dental X-ray :

Place a mark on "yes" or "no" to indicate if you have hadany of the following

	Yes		No	Bad Breath		Yes		No	Mouth breathing
	Yes		No	Burning Sensation on longue		Yes		No	Mouth pain, brushing
	Yes		No	Chew on one side of mouth		Yes		No	Orthodontic treatment
	Yes		No	Cigarette, Pipe or Cigar Smoking		Yes		No	Pain around ear
	Yes		No	Clicking or popping jaw		Yes		No	Periodontal treatment
	Yes		No	Dry mouth		Yes		No	Sensitivity to cold
	Yes		No	Fingernail biting		Yes		No	Sensitivity to heal
	Yes		No	Food collection between teeth		Yes		No	Sensitivity to sweet
	Yes		No	Foreign objects		Yes		No	Sensitivity when biting
	Yes		No	Grinding teeth		Yes		No	Sores or growths in your mouth
	Yes		No	Gums swollen or tender

Physician's Name :

Date of Last Visit :

Have you ever taken any of the group of drugs collectively reterred to as "ten ohen"? These include combination of lonimin. Adipex, Fastin (brand names of Phentermine). Pondimin (Fenfluramine) and Redux (dexetenfluramine) Yes No

Place a mark on "Yes" or "No" to indicate if you have had any of the following

	Yes		No	AIDS/HIV		Yes		No	Jaw Pain
	Yes		No	Anemia		Yes		No	Kidney Disease
	Yes		No	Arthritis, Pheumatism		Yes		No	Liver Disease
	Yes		No	Artificial Heart Valves		Yes		No	Low Blood Pressure
	Yes		No	Artificial Joints		Yes		No	Mitral Valve Prolapse
	Yes		No	Asthma		Yes		No	Nervous Problems
	Yes		No	Back Problems		Yes		No	Pacemaker
	Yes		No	Bleeding abnormally, with extractions or surgery		Yes		No	Psychiatric Care
	Yes		No	Blood Disease		Yes		No	Radiation Treatment
	Yes		No	Cancer		Yes		No	Respiratory Disease
	Yes		No	Chemical Dependency		Yes		No	Pheumatic Fever
	Yes		No	Chemotherapy		Yes		No	Scarlet Fever
	Yes		No	Circulatory Problems		Yes		No	Shortness of Breath
	Yes		No	Congenital Heart Lesions		Yes		No	Sinus Trouble
	Yes		No	Cortisone Treatments		Yes		No	Skin Rash
	Yes		No	Cough, persistent or bloody		Yes		No	Special Diet
	Yes		No	Diabetes		Yes		No	Stroke
	Yes		No	Emphysema		Yes		No	Swollen Feet or Ankles
	Yes		No	Epilepsy		Yes		No	Swollen NEck Glands
	Yes		No	Fainting or dizziness		Yes		No	Thyroid Problems
	Yes		No	Glaucoma		Yes		No	Tonsillitis
	Yes		No	Headaches		Yes		No	Tuberculosis
	Yes		No	Heart Murmur		Yes		No	Tumor or growth on head or neck
	Yes		No	Heart Problems		Yes		No	Ulcer
	Yes		No	Hepatitis Type		Yes		No	Venereal Disease
	Yes		No	Herpes		Yes		No	Weight Loss, Unexplained
	Yes		No	High Blood Pressure		Yes		No	Blood Thinners
	Yes		No	Jaundice

Do you wear contact lenses? Yes No

Women

Are you pregnant? Yes No

Due Date:

Are you Nursing? Yes No

Taking Birth Control Pills? Yes No

Medications

List any Medications you are currently taking and the correlating dignosis

Pharmacy Name:

Phone:

Allergies

Aspirin Barbiturates (Sleeping Pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Other

Has there been any change in your health since your last dental appointment? Yes No

For What Conditions?

Are you talking any new medications? Yes No

if so what?

Our office policy implemented in april of 2012

After a proposed treatment plan has been estabilished for you we will be able to give you an estimate as to what your portion for this treatment will be. We request that you pay 50% of this amount at the time you schedule your appointment. the remaining blance is to be paid upon the completion of the treatment

We do offer Care Credit and the Careington plan to help you with your dental expenses. Please ask one of the front desk personal for information.

For your convenience we do accept cash, check and credit card when making your payment. if you per-pay 100% of your portion a 5% discount will be given.

I have read and understand this policy

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