• 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
  • |
  • MARRIEDSINGLEDIVORCEDSEPARATED
  • 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:
  1. 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.

  2. 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.
  1. A 5% reduction in your fee if you pay for services in advance of the treatment being initiated.
  2. Payment by appointment. This option allows you to spread out the payments according to your treatment plan.
  3. Payment with Mastercard, Visa, Discover and American Express. This will allow you to comfortably budget your monthly payments.
  4. 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
  5. 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.
  6. 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?
  • YESNO
  • 2. Date of last physical examination
  • 3. Are you now under the care of a physician?
  • YESNO
  • If so, what is the condition being treated?
  • 4. Have you ever been hospitalized?
  • YESNO
  • If so, please explain
  • 5. Are you taking any medicine?
  • YESNO
  • If so, What?
  • 6. Have you been pre-medicated with antibiotics for your dental treatment?
  • YESNO
  • 7. Are you sensitive or allergic to anything?
  • YESNO
  • 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?
  • YESNO
  • 11. Do you have any disease, condition or problem not listed?
  • YESNO
  • 12. (Women) Are you Pregnant? If so, how many months?
  • YESNO
  • 13. (Women) Do you take Birth Control Pills?
  • YESNO
  • DENTAL HISTORY
  • 1. Have you ever had a local anesthetic (Novocaine, etc.)?
  • YESNO
  • 2. Have you ever had any unfavorable reaction from a local anesthetic?
  • YESNO
  • 3. Have you had difficulty associated with any previous dental treatment?
  • YESNO
  • 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?
  • YESNO
  • If YES. Check
  • SlightlyModeratelyExtremely
  • 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

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