| Date |
|
| Patient |
|
| Sex |
|
Date of Birth
|
|
| Age |
|
| Address |
|
| City |
|
| State |
|
| Zipcode |
|
| Home Telephone |
|
| Cell Phone |
|
| Email Address |
|
| Martial Status |
|
| Occupation(s) |
|
| Place of Employment |
|
| Address of Employer |
|
| Business Telephone |
|
| Business Fax |
|
| Would you like to be contacted
by email to confirm future appointments? |
Yes
No |
| If a minor, name of parent
/guardian and phone number for emergency contact: |
|
| Person financially responsible
for your dental care: |
|
| Name |
|
| Relationship |
|
| Address |
|
| City |
|
| State |
|
| Zipcode |
|
| Telephone |
|
| Do you have Dental Insurance? |
Yes No |
| Name of Policy Holder |
|
| Policy Holder Date of Birth |
|
| Policy Holder Employer |
|
| Payment will be made by: |
Cash Check
C.C. |
| Driver License No. |
|
| Height |
|
| Weight |
|
| Name of Physician |
|
| Telephone |
|
| Whom may we thank for
referring you to us? |
|
| Why did you leave your last
dentist? |
|
| Have you ever been a patient
in our office before? |
Yes
No |
| Date of last dental visit? |
|
| Reason for last visit? |
|
| Do you have any of your x-rays
or dental records? |
Yes
No |
| Nearest relative not living
with you? |
|
|
Have you EVER
had any of the following? (Check Yes or No) |
|
| Heart Trouble |
Yes No |
| Chest Pain |
Yes
No |
| Heart Murmur |
Yes
No |
| Pacemaker |
Yes
No |
| Hypertension/HI. Blood
Pressure |
Yes No |
| Rheumatic Fever |
Yes No |
| Joint Implant |
Yes No |
| Diabetes |
Yes
No |
| Asthma |
Yes
No |
| Lung Disease |
Yes
No |
| Drug Allergy |
Yes
No |
| Seizures |
Yes
No |
| Blood Disease |
Yes No |
| Kidney Disease |
Yes No |
| Shortness of Breath |
Yes
No |
| Liver Disease |
Yes No |
| Low Blood Pressure |
Yes No |
| Anemia |
Yes
No |
| Epilepsy |
Yes
No |
| Major Surgery |
Yes No |
| Hepatitis |
Yes
No |
| AIDS Virus |
Yes
No |
| Glaucoma |
Yes
No |
| Thyroid Condition |
Yes No |
| Parkinsons Disease |
Yes No |
| |
| If you were to change
something about your teeth or smile, what would you do? |
|
Are you presently in any
dental plan?
If YES, explain |
|
Is any part of your mouth
sensitive to temperature or chewing?
If YES, explain |
|
Does food catch between your
teeth?
If YES, explain |
|
Are you aware of your jaw
clicking or popping while eating or yawning?
If YES, explain |
|
Do you have frequent
headaches?
If YES, explain |
|
Are you allergic
to:
Penicillin
Codeine
Aspirin
Local Injected Anesthetics
Other |
Are you now under the care of
a physician for any reason?
If YES, explain |
|
| Are you now or have you been taking drugs or
medications? |
|
Have you ever received Radiation Therapy
(i.e. for tumors) of the face, head, neck or jaws?
If YES, explain |
|
Do you have a problem with bleeding or
clotting?
If YES, explain |
|
Are there any other medical conditions of
which we should be aware?
If YES, explain |
|
| General Physical Condition |
|
| When was your last physical examination? |
|
Was anything unusual or abnormal found?
If YES, explain |
|
| Female Patients: Are you taking birth
control pills? |
Yes No |
| Are you, or could you be pregnant? |
Yes
No |
| If so, name and number of OB/GYN |
|
| Please be
reminded that payment is due on the date which services are
rendered. Other arrangements must be made in advance. |
|
| |
|
Professional Fees
|
|
| 1. I understand that substantial time is
reserved for each treatment session and that additional charges
may be applied for tardiness, broken appointments, and cancelled
appointments without at least 24 hours notice. |
|
| 2. I understand that occasionally a tooth
which has received dental treatment will require further
treatment, and if necessary, an addional fee may be charged. |
|
| 3. I understand that professional fees are
levied at the time services are intiated and are due in full
before or upon completion of treatment. I further understand
that a finance charge equal to 18% (APR) will be applied on
account balances beginning thirty days from the date treatment
is completed. |
|
| 4. I understand that the professional
services are rendered and charged to me, not the insurance
company. I understand that services cannot be rendered to me on
the assumption that professional fees will be paid by an
insurance company. A predetermination of benefits must precede
treatment and an assignment of benefits made to the doctor if
insurance benefits are to be used for payment of professional
services. |
|
| 5. I understand that if my account should
be turned over for legal collection, I agree to pay for all cost
of collection including postage, court costs, and attorney fees.
|
|
|
Clicking on
the
Submit Button
acknowledges
you have understood and agreed to the Professional Fees and have
supplied accurate and complete information in this
Health History Form
to the best of
your abilities. |
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