Secondary Insurance

Dental Coverage?   Yes   No

Insurance Co. Name:_________________________________

Insurance Co. Address:_______________________________
_________________________________________________

Insurance Co. Phone#: ______________________________

Group# (Plan, Local or Policy#): _______________________

Insured's Name: __________________ Relation: __________

Insured's Birthdate: ___/ ___/___ Insured's ID#: _________

Insured's Employer: _________________________________

Employer's Address: _________________________________
_________________________________________________

 
Payment is due in full at the time of treatment
unless prior arrangements have been approved.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

________________________________________________
Signature                                                            Date

Primary Insurance

Dental Coverage?     Yes  No

Insurance Co. Name: ________________________________

Insurance Co. Address: ______________________________
_________________________________________________

Insurance Co. Phone#: _______________________________

Group# (Plan, Local or Policy#): ________________________

Insured's Name: __________________ Relation: ___________

Insured's Birthdate: ___/ ___/____ Insured's ID#: __________

Insured's Employer: __________________________________

Employer's Address: __________________________________
__________________________________________________ 

Today's Date:  ___________

E-mail Address: _____________________________________
 
Name: ____________________________________________

 
I prefer to be called: ___________________      Male   Female

Birthdate: ____/____/____ Age: _____ SS#:______________

Home Adress:_______________________________________
__________________________________________________

Single Married Partnered Divorced/Separated Widowed 

Hm#: ____________________ Cell/Other#:_________________

Wk#: ____________________ Ext. ______ DL#: ____________

Employer: ____________________________________________

Employer's Address: ____________________________________
____________________________________________________

How long there? ________ Occupation: ____________________

Where & when are best times to reach you? _________________

Whom may we thank for referring you? _____________________

Other family members seen by us: _________________________

Previous/present dentist: ________________________________

Person Responsible for Account: ____________________

His/her name: _________________________________________

Employer: ____________________________________________

Wk#: __________________ Ext: _______ SS#: _____________

Birthdate: ____/____/_____ DL#: ________________________

Relative or friend not living with you.

His/her name: ____________________ Relation:_____________

Wk#: ______________________ Hm: _____________________

ABOUT YOU

INSURANCE

SPOUSE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

Do you have a personal physician?              Yes     No

Physician's Name: ___________________________________

Phone: ___________________ Date of last visit: __________

Your current phyisical health is:      Good    Fair    Poor

Are you currently under the are of any physician?      Yes    No
Please explain: ______________________________________

Do you smoke or use tabacco in any other form?        Yes    No

Have you had any mental rods, pins or implants?        Yes     No

Are you taking prescription/over-the-counter drugs?  Yes   No

Please list each one: _________________________________

Have you ever taken Phen-Fen?            Yes    No
Also known as Redux or Pondimin.
If so, when? _______________________________________

For Women: Are you using a prescribed    Yes   No
method of birth control?

Are you pregnant?    Yes     No      Week#: _____________

Are you nursing?     Yes     No

Have you ever had any of the following diseases or medical problems:

Y  N Abnormal Bleeding/Hemophilia
Y  N AIDS
Y  N Alcohol/Drug Abuse
Y  N Anemia
Y  N Arthritis
Y  N Artificial Bones
Y  N Asthma
Y  N Blood Transfusion
Y  N Cancer/Chemotherapy
Y  N Colitis
Y  N Congenital/Heart Defect
Y  N Diabetes
Y  N Difficulty Breathing
Y  N Emphysema
Y  N Epilepsy
Y  N Fainting Spells
Y  N Frequent Headaches
Y  N Gloucoma
Y  N Hay Fever
Y  N Heart Attack/Surgery
Y  N Heart Murmur
Y  N Hepatitis

Please list any serious medical condition(s) that you have ever had: _____________________________________________

Are you allergic to any of the following?

Y  N Aspirin                       
Y  N Codeine                  
Y  N Dental Anesthetics

Please list any other drugs/materials that you are allergic to:_______________________________________________    

Y   N Herpes/Fever Blisters
Y   N High Blood Presure
Y   N HIV
Y   N Hospitalized for Any Reason
Y  N Kidney Problems
Y  N Liver Disease
Y  N Low Blood Pressure
Y  N Lupus
Y  N Mitral Valve Prolapse 
Y  N Pacemaker
Y  N Psychiatric Problems
Y  N Radiation Treatment
Y  N Rheumatic/Scarlet Fever
Y  N Seizures
Y  N Shingles
Y  N Sickle Cell Disease/Traits
Y   N Sinus Problems
Y   N Stroke
Y   N Thyroid Problems
Y   N Tuberculosis (TB)
Y   N Ulcers
Y   N Venereal Disease

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

MEDICAL HISTORY UPDATE

Has ther ebeen any change in your health status since your last visit?    Y   N
If Yes, please explain: ____________________________________________

Has there been any change in your health status since your last visit?  Y  N
If Yes, please explain. ____________________________________________

_________________________________
Patient Signature                       Date
______________________________________
Dentist Signature                       Date
______________________________________
Patient Signature                       Date
______________________________________
Dentist Signature                       Date

Why have you come to the dentist today? ________________
__________________________________________________

Are you currently in pain?    Yes   No

Do you require antibiotics before dental treatment?   Yes  No

Have you ever had a difficult problem associated with any previous dental work?    Yes  No

Do you floss daily?   Yes  No     Ever Itch?   Yes  No 

Types of bristles on your toothbrush?  Hard  Medium  Soft

Have you ever had periodontal disease?     Yes    No

Have you ever gum treatment?   Yes   No

Do your gums ever bleed?      Yes    No

Do you now or have you ever experienced         Yes     No
pain/discomfort in your jaw joint (TMJ/TMD)?

Are you teeth sensitive to heat, cold,             Yes    No
or anything else?

Do you have any loose teeth?        Yes     No

Do you still have wisdom teeth?     Yes     No

Would you like freshner breath?    Yes     No 
Whiter teeth?   Yes    No

Are you happy with the way your smile looks?   Yes   No
If not, what would you change? ________________________
__________________________________________________

I understand that the information that I have given today is correct to be the best of my knowledge. I also understand that is this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.

___________________________________________________
Signature                                                            Date

OFFICE USE ONLY OFFICE USE ONLY

I verbally reviewed the medical/dental information with the patient named herein.

Initials: ___________________________ Date: __________

Doctor's Comments: ________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

The benefits of happy, healthy smile are immeasurable!
Our goal is to to help you reach and maintain optimaloral health. 
Please fill out this form completely. The better we communicate, the better we can care for you.