First Name
Last Name
Middle Initial
Patient Is: Policy Holder Responsible Party
Preferred Name
Responsible Party (if someone other than the patient)
Address
City, State, Zipcode
Birth Date
Home Phone
Cell Phone
Work Phone
Ext
Social Security
Driver's License
Responsible Party is also a Policy Holder for Patient
Primary insurance Policy Holder
Secondary insurance Policy Holder
Patient Information
Age
Sex MaleFemale
Marital Status SingleMarriedDivorcedSeparatedWidowed
E-mail
Correspondences I would like to receive correspondences via e-mail
Employment Status Full Time Part Time Retired
Students Status Full Time Part Time
Referrel Source Encore Launch Loyalty Discount PlanWord of Mouth Walk In[checkbox pat_ReferrelSource "PPO Insurance"[checkbox pat_ReferrelSource "Online"] Drive ByMedicaid
Medicaid Id
Pref. Dentist
Employer Id
Pref. Pharmacy
Carrier id
Pref. Hygenist
Primary Insurance Information
Name of Insured
Relationship to Insured SelfSpouse ChildOther
Insured Social Security
Insured Dtae Of Birth
Employer
Ins. Company
Address 2
Address 3
Remaining Benefits
Remaining Deductible
Secondary Insurance Information
Email Address
Patient Name
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Has anyone ever said you snore? YesNo
If yes, please explain:
Do your tissues ever bleed upon brushing or flossing? YesNo
Are you under a physician's care now? YesNo
Have you ever been hospitalized or had a major operation? YesNo
Have you ever had a serious head or neck injury?
YesNo
Are you taking any medications, pills, or drugs? YesNo
Do you take, or have you taken, Phen-Fen or Redux? YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo
Are you on a special diet? YesNo
Do you use tobacco? YesNo
Do you use controlled substances? YesNo
Women Are you: ?
Pregnant/Trying to get pregnant? YesNo
Taking oral contraceptives? YesNo
Nursing? YesNo
Are you allergic to any of the following? AspirinPenicillinCodeineLocal Anesthetics AcrylicMetalLatexSulfa drugsOther
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Cortisone Medicine
Hemophilia
Radiation Treatments
Alzheimer's Disease
Diabetes
Hepatitis A
Recent Weight Loss
Anaphylaxis
Drug Addiction
Hepatitis B or C
Renal Dialysis
Anemia
Easily Winded
Herpes
Rheumatic Fever
Angina
Emphysema
High Blood Pressure
Rheumatism
Arthritis/Gout
Epilepsy or Seizures
High Cholesterol
Scarlet Fever
Artificial Heart Valve
Excessive Bleeding
Hives or Rash
Shingles
Artificial Joint
Excessive Thirst
Hypoglycemia
Sickle Cell Disease
Asthma
Fainting Spells/Dizziness
Irregular Heartbeat
Sinus Trouble
Blood Disease
Frequent Cough
Kidney Problems
Spina Bifida
Blood Transfusion
Frequent Diarrhea
Leukemia
Stomach/Intestinal Disease
Breathing Problem
Frequent Headaches
Liver Disease
Stroke
Bruise Easily
Genital Herpes
Low Blood Pressure
Swelling of Limbs
Cancer
Glaucoma
Lung Disease
Thyroid Disease
Chemotherapy
Hay Fever
Mitral Valve Prolapse
Chest Pains
Heart Attack/Failure
Osteoporosis
Cold Sores/Fever Blisters
Heart Murmur
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Heart Pacemaker
Parathyroid Disease
Ulcers
Convulsions
Heart Trouble/Disease
Psychiatric Care
Venereal Disease
Yellow Jaundice
Tonsillitis
Tuberculosis
Have you ever had any serious illness not listed above? YesNo
If yes, please explain
What can we do to make you a patient for life?
If you had a magic wand and could change anything about your smile what would it be?
How loang has it been since your last dental visit?
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
DATE
SECTION A: PATIENT GIVING CONSENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR)
Name
Telephone
SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of your Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person
Right To Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
Signature
Date
