Patient Form How did you hear about us? Patient Name * First Name Last Name Today's Date * I have been a patient here, before today: (Click One) * Yes No Please check all that apply. Recommended by a friend, family member, or colleague (name): Social Media (e.g. Facebook, Instagram, Twitter) Our website Search engine (e.g. Google, Bing) - If so, which keywords were used to search? Advertisement (e.g. Radio, Newspaper): Reviews Site (e.g. Google Reviews, Yelp): Other (e.g. Insurance): Title * MR. MRS. MS. DR. Preferred Name Best Contact Number (###) ### #### Address City, State, Zip Email Emergency Contact Name Relation Emergency Contact's Phone Number (###) ### #### Previous Dentist Last dental visit Previous Dentist's Phone Number (###) ### #### HIPPA POLICY **If you have filled out this form digitally, you will receive a copy of this office's Notice of Privacy Practices upon arrival. You may also refuse to sign this acknowledgement.** I acknowledge that I have received and read a copy of this office's Notice of Privacy Practices Digital Signature: Date: CONSENT TO DISCUSS TREATMENT In the event of a spouse, parent, or child who calls our office or is present with you at your appointment; we are not able to give out any information regarding your treatment, when your next appointment is scheduled, etc. Unless you list them as someone we are allowed to discuss this with below. I do not wish to have my dental appointments or treatment discussed with anyone. I hereby give consent to this dental practice to have my dental treatment or appointments discussed in front of or over the phone with this office. Digital Signature Date: DENTAL HISTORY 1. Do your gums bleed when you brush or floss? Yes No 2. Are your teeth sensitive? Yes No 3. Does food or floss catch between your teeth? Yes No 4. Is your mouth dry? Yes No 5. Have you had any gum treatment? Yes No 6. Have you had braces? Yes No 7. Have you ever had any issues with dental treatment? Yes No 8. Are you currently experiencing any pain? Yes No 9. Do you have ear or neck pain? Yes No 10. Do you have clicking or popping in your jaw? Yes No 11. Have you ever had a serious head or mouth injury? Yes No 12. Do you have any loose teeth? Yes No 13. Do you have dentures or partial dentures? Yes No MEDICAL HISTORY Primary physician's name: Phone #: (###) ### #### Are you currently under the care of a physician? Yes No If yes, for what: Date of your last physical exam: **It is recommended by the ADA to have antibiotics prior to any dental treatment, including cleanings, if you have any history of Congenital Heart Disease (CHD), artificial/prosthetic values or any previous infective endocarditis** As office policy, if you have had any full joint replacement surgery within the last year of your appointment date, we require a clearance letter from your surgeon , as antibiotics may be recommended before treatment. Do you use controlled substances (drugs)? Yes No Do you drink alcohol? Yes No If yes, how often? Do you take or have you ever taken Phen-Fen or Redux? Yes No Have you ever taken Fosamax, Bonita, Acetonel or any other medications containing Biphosphonates? Yes No Are you on a special diet? Yes No Has a doctor or dentist ever recommended you take antibiotics before dental appointment? Yes No Women Only: Are you pregnant? Yes No Taking birth control pills or hormone replacement? Yes No 14. Do you have any unhealed oral injuries, growths, or spots in your mouth? Yes No 15: have you been hospital within the past 5 years? Yes No 16. Is there any condition concerning your health that the doctor should be told? Yes No 17. Do you currently take any blood thinners? Yes No Have you had or have any of the following conditions? Abnormal/ Excessive bleeding AIDS or HIV infection Alzheimer's disease Anaphylaxis Anemia Angina Arthritis/Gout/Joint Disease Artificial Heart Valve Artificial Joints Asthma Autoimmune Disease Blood Disease Blood Transfusion Breathing problems/difficulty Bronchitis, Chronic Cough Bruise Easily Cancer Cardiovascular Disease Chemo/Radiation Therapy Chest Pains Chronic Fatigue Cold Sores / Fever Blisters Congenital Heart Disorder Congestive Heart Failure Contagious Disease Convulsions Cortisone Medicine Damaged Heart Values Delay in healing Diabetes Dialysis Drug Addition Eating Disorder Emphysema Epilepsy Excessive Thirst Fainting Spells/Seizures Frequent Diarrhea Frequent Headaches Gallbladder Trouble Gentical Herpes GERD/Heartburn Glaucoma Hay Fever Heart Attack / Stroke / Failure Heart Murmur Heart Surgery Heart Trouble / Disease Hemophilia Hepatitis A Hepatitis B or C Herpes/Cold Sores/Fever Blister High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Immune System Problems Irregular Heartbeat Joint Replacements Kidney Disease / Problems Leukemia Liver Disease Low Blood Pressure Low Blood Sugar Lung Disease Mitral Valve Prolapse Mononucleosis Osteoporosis Pacemaker Psychiatric Treatment / Care Recent Weight Loss Recurrent Infections Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease / Traits Sinus problems Spina Bifida Stomach Disease Swelling of Limbs Thyroid Problems / Disease TMJ, Jaw Pain Tonsillitis Tuberculosis (TB) Tumors or Growths Ulcers Venereal Disease Do you have any disease, condition or problem that was not listed above? ALLERGIES - Are you allergic to or have you had any type of reaction to: Local Anesthetics Aspirin Pencillin or other antibiotics Barbiturates, sedatives or sleeping pills sulfa drugs codeine or other narcotics Latex Authorization, Release, and Agreement to Pay for Services Rendered I understand that with dental insurance, the copay of total fee is expected at the time services are rendered. I also understand that for my convenience the dentist accepts cash, check or credit card and I hereby agree to pay the copay today for the services rendered to me. Without dental insurance, fees are due when service is rendered; afterwards it is the patient’s responsibility to return if treatment is not completed on the first visit. Thank you!
