About You:
Name ___________________________________________________ I prefer to be cal ed ______________________________
Birthdate _____________________ Age ______ Social Security # _________________________ Male _____ Female _____
Home phone ______________________________ Wireless phone __________________ Work phone __________________
E-mail address _______________________________________________ Driver’s license # _____________________________
Employer _______________________________ Whom may we thank for referring you? ____________________________
Spouse or person responsible for account other than yourself_________________________________________________
Relation __________ Social Security # _____________________ Phone __________________ Employer ________________
Medical History:
Do you require antibiotics before dental treatment? ________________________________________________
Are you allergic to any medicine? __________ If so, what?___________________________________________
Do you have?
Are you taking any of the following?
Blood Thinners/Aspirin ______________________________________ Blood Pressure Medicine ___________________________________ Bisphosphonates (Fosamax, Boniva) ________________________ Insulin/Diabetes Drugs______________________________________ __Thyroid problems
Recreational/Street Drugs/ History of abuse? ________________ Statins/Cholesterol medicine _______________________________ __Latex Allergy
Thyroid Medicine __________________________________________ __Heart Disease/Surgery
List any other medicines ___________________________________ ___________________________________________________________ Significant present/past medical problems not listed above:__________________________________________________
Are you currently under the care of a physician?_____________________________________________________________
Physician’s name and phone number _______________________________________________________________________
Dental History: Why have you come to the dentist today___________________________________________
Do your gums bleed?_____
Have you had periodontal (gum)treatment? _____ Does your jaw ever lock open/closed? _____ Do you hear clicking/popping when you chew? _____
Dental Insurance Information:
Insurance Company Name ___________________________________________ Employer____________________________ Insured’s Name (if not self) ____________________________________________Relation _____________________________ Insured’s Social Security # __________________________________ Insured’s Birthdate ____________________________ Insured’s Employer _________________________________________________________________________________________ Authorizations:
I certify that I am covered by _________________________________________ insurance company and I assign payment directly to Dr. Atchley for services rendered. I am responsible for paying al co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure payment of benefits. I authorize the use of this signature on al my insurance submissions, whether manual or electronic. Signature __________________________________________________________________ Date __________________________ I affirm that the information I have given is correct to the best of my knowledge. It wil 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 the necessary dental services I may need. 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. I have had ful opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment payment activities, and healthcare operations. I also understand that I have the right to revoke permission. The privacy policy of this office has been made available to me. (Initial) _____________ If unable to keep your appointment, kindly give a 24 hour notice, otherwise a charge wil be made for time reserved. (initial) _____________ Signature __________________________________________________________________ Date __________________________ PAYMENT IS DUE AT TIME OF SERVICE.

Source: http://www.dratchley.com/pdf/health-hx.pdf


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