PATIENT INFORMATION THE INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL Patient's name Birthdate Residence address Phone Cell City State Zip E-mail MARRIED SINGLE DIVORCED SEPARATED Driver's license no. Social security no. Employed by No. of years Occupation Business address Phone City State Zip Spouse or parent's name Birthdate Address Phone City State Zip Social security no. Employed by No. of years Occupation Business address Phone City State Zip Whom may we thank for referring you to our office? Name of nearest relative not living with you Complete address Phone City State Zip Name of physician Phone Former dentist Phone Person responsible for this account Relationship Address Phone City State Zip Consent for treatment: The undersigned hereby authorizes doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient's needs. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment. Signature Date DENTAL INSURANCE INFORMATION Insurance company Group no.or local Address Phone City State Zip Insured person's name Date of birth Social security number Employee no. Secondary insurance company Group no.or local Address Phone City State Zip Insured person's name Date of birth Social security number Employee no. If patient is a student, name of school or college Insurance authorizetion I authorize release of information to all my insurance carriers. I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. Signature Date FINANCIAL POLICY Our financial policy is payment is due at the time of treatment. We will inform you of the fee of your recommended treatment at the time it is diagnosed. And offer financing options. We believe these options will prove to be a service to you and your family. A 5% reduction in your fee if you pay for services in advance of the treatment being initiated. Payment by appointment. This option allows you to spread out the payments according to your treatment plan. Payment with Mastercard, Visa, Discover and American Express. This will allow you to comfortably budget your monthly payments. Insurance on assignment. As a service to you, we will continue to file your insurance and accept assignment of benefit from your insurance company. This will help reduce your immediate 'out of pocket' expenditures - only the estimated private pay monies will be due at the time of treatment Long term or extended financing will be offered through Care Credit. This is our new financial partner that will allow our patients to invest in their oral health with small monthly payments over an extended period of time. A finance charge of 18% may be added to outstanding balances. I understand that all responsibility for payment for dental services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered. Signature Date HEALTH HISTORY These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are associated with proper oral health care. Please answer each question. Circle YES or NO where applicable. MEDICAL HISTORY 1. Are you in good health? YES NO 2. Date of last physical examination 3. Are you now under the care of a physician? YES NO If so, what is the condition being treated? 4. Have you ever been hospitalized? YES NO If so, please explain 5. Are you taking any medicine? YES NO If so, What? 6. Have you been pre-medicated with antibiotics for your dental treatment? YES NO 7. Are you sensitive or allergic to anything? YES NO If so, What? 8. Do you have, or have you had any of the following: (Please check known conditions) Anemia Blood Transfusion Herpes Joint replacement Stroke Nervous Disorders Heart Murmur Tuberculosis (T.B.) Bruise Easily Hepatitis or Jaundice Angina Pectoris Venereal Disease Psychiatric Treatment Rheumatic Fever Hay Fever High Blood Pressure Chicken Pox Heart Ailments or Attack Cold Sores Pain in Jaw Joints Hemophilia Respiratory Disease Rheumatism Ulcers Kidney Disease Diabetes Allergies or Hives Glaucoma Cortisone Medicine Arthritis Emphysema Asthma Scarlet Fever Difficulty in Swallowing Cerebral Palsy Sinus Trouble X-Ray or Cobalt Treatment Blood Disease Fainting Spells or Seizures Drug Addiction Chemotherapy (Cancer, Leukemia) Tumors or Growths Radiation Treatment, any kind Epilepsy or Seizures Head Injuries Artificial Prosthesis Excessive Bleeding Liver Disease Congenital Heart Lesions Thyroid Disease Tonsillitis AIDS Related Complex Other 10. Do a Cardiac pacemaker, or have you had heart surgery? YES NO 11. Do you have any disease, condition or problem not listed? YES NO 12. (Women) Are you Pregnant? If so, how many months? YES NO 13. (Women) Do you take Birth Control Pills? YES NO DENTAL HISTORY 1. Have you ever had a local anesthetic (Novocaine, etc.)? YES NO 2. Have you ever had any unfavorable reaction from a local anesthetic? YES NO 3. Have you had difficulty associated with any previous dental treatment? YES NO If so, explain 4. How long since your last dental treatment? 5. How long since your last X-Rays? 6. Does dental treatment make you nervous? YES NO If YES. Check Slightly Moderately Extremely To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any changes in my health or if my medications change, I will, without fail, inform the doctor at my next appointment. Signature Date MEDICAL HISTIORY UPDATE Date By Date By Date By Date By Please enter code above in the field below.