WELCOME TO OUR PRACTICE Patient Information
Sex: Male Female Marital Status: Married Single Divorced Separated
Responsible Party (if someone other than patient) Spouse and/or Parent Information
Responsible Party is also a Policy Holder for Patient
Primary Insurance Information Responsible Party (if someone other than patient) Spouse and/or Parent Information
Responsible Party is also a Policy Holder for Patient
Primary Insurance Information
Relationship to Patient: Self Spouse Child Other
How long since your last dental cleaning?
Have you ever had a serious/difficult problem associated with any previous dental work? Yes No
Do you or have you ever experienced discomfort/pain in your jaw joint (TMJ/TMD)? Yes No
Your current dental health is Good Fair Poor
Are your gums swollen and/or tender? Yes No
Do you have bad breath even with regular brushing and/or mouthwash? Yes No
Are you aware of any sores or growths in your mouth?
Do you regularly collect food between any of your teeth?
Are any teeth sensitive to heat, cold or sweets?
Have you had orthodontic treatment? Yes No
Are you concerned about the health effects of metal fillings?
Are you concerned about the appearance of metal fillings?
Are you interested in preventive treatment against decay?
Are you interested in improving the appearance of your smile?
Are you interested in whitening your teeth?
To the best of my knowledge, the questions on this form have been accurately answered. i understand that providing incorrect information can be dangerousto my (or patientʼs) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT , OR GUARDIAN
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.
Have you recently been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Do you take, or have you taken, Phen-Fen or Redux?
Are you taking any prescription or over the counter drugs?
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
Do you have, or have you had, any of the following?
Have you ever had any serious illness not listed above Yes No
Are you being treated for osteoporosis? Yes No
Have you taken any of the drugs listed below? For how long? For what treatment?
ABOUT FINANCIAL ARRANGEMENTS AND DENTAL INSURANCE
If you have dental or medical insurance, we are eager to help you receive your maximum allowablebenefits. In order to achieve these goals, we need your assistance and your understanding of ourpayment policy.
Payment is due at the time services are rendered. We accept cash, check and most major credit cards. We will be happy to process your insurance claim for you as we accept assignment of insurance benefits, however, we ask that payment for any out-of-pocket expenses be paid at the time of treatment. IN ALL CIRCUMSTANCES THE PATIENT IS RESPONSIBLE FOR ALL COSTS NOT PAID BY THE INSURANCE COMPANY. Returned checks and balances older than 30 days will be subject to additional collection fees (and interest charges of 1 1/2% per month). Charges may also be made for broken appointments and appointments cancelled without 24 hours advance notice.
We will gladly discuss your proposed treatment and answer any questions relating to your insurance.
Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. It is your responsibility to be sure your insurance isin effect and up to date.
Our fees are generally considered to fall within the acceptable range by mostcompanies and therefore are covered up to a maximum allowance determined by eachcarrier. This applies only to companies who pay a percentage (such as 50% or 80%) of“U.C.R.”. “U.C.R.” is defined as usual, customary and reasonable fees for this region. Thus, our fees are considered usual, customary and reasonable by most companies. Please understand the amount we figure is only an estimate. This statement does not apply to companies who reimburse based on an arbitrary“schedule” of fees, which bears no relationship to the current standard and cost of carein this area.
Not all services are a covered benefit in all contracts. Some insurance companiesarbitrarily select certain services they will not cover.
We must emphasize that as dental care providers, our relationship is with you, not your insurancecompany. While filing insurance claims is a courtesy that we extend to our patients, all charges are yourresponsibility from the date the services are rendered. We realize that temporary financial problems mayaffect timely payment of your account. If such problems do arise, we encourage you to contact uspromptly for assistance in the management of your account.
If you have any questions about the above information or any uncertainty regarding insurance coverage,PLEASE donʼt hesitate to ask us. We are here to help you.
Responsible Party and/or Patient Signature Date
Información Importante Sobre Medicamentos yAlimentos Del Centro Clínico Warren Grant Magnuson, Institutos Nacionales de SaludFuerza Operativa Sobre la Interacción de Medicamentos-Nutrientes Información importante que debe saber cuando esté tomando alguno de los siguientes medicamentos: Amiodarone (Cordarone,® Pacerone®) Lovastatin (Mevacor®)Buspirone (Buspar®) Nifedipine La tor
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