Patient’s Information (Confidential)

Responsible Party

CORAL GABLES DENTAL HEALTH CENTER, P.A.

WelcomeThank you for selecting our dental healthcare team!We will strive to provide you with the best possible dental care.To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us - We will be happy to help.

Name: Birth Date:Home Phone: Cell Phone: E-mail:Address: City: State: Zip:Check Appropriate Box: Minor Single Married Divorced Widowed Separated Patient's or Parent's Employer: Work Phone: Business Address: City: State: Zip:Spouse or Parent's Name: Employer: Work Phone: If Patient is a Student, Name of School/ College: City: State: Zip:Whom May We Thank for Referring you? Person to Contact in Case of Emergency: Phone:

Name of Person Responsible for this Account: Relationship to Patient: Address: Home Phone:Driver's License#: Birthdate: Financial Institution:Employer: Work Phone: Is this Person Currently a Patient in our Office? Yes NoInsurance InformationName of Insured: Relationship to Patient: Birthdate: S.S.#: Date Employed:Name of Employer: Work Phone:Address of Employer: City: State: Zip:Insurance Company: Group#: Union or Local#: Ins. Co. Address City: State: Zip:How Much is your Deductible? How Much Have You Used? Max. Annual Benefit Do you have any additional insurance? Yes No If yes, complete the following:Name of Insured: Relationship to Patient: Birthdate: S.S.#: Date Employed:Name of Employer: Work Phone:Address of Employer: City: State: Zip:Insurance Company: Group#: Union or Local#: Ins. Co. Address City: State: Zip:How Much is your Deductible? How Much Have You Used? Max. Annual Benefit

Date:Patient #:S.S #:

Over Please

Patient’s Medical History

Patient’s Dental History

Authorization and Realease

Physician: Office Phone:Yes No Yes No

1. Are you under medical treatment now?2. Have you ever been hospitalized for any surgical operation or serous illness?3. Are you taking any medication(s) including non-prescription medicine?If Yes, what medication(s) are you taking?

4. Do you use tobacco?5. Do you use alcohol, cocaine or other drugs?6. Are you wearing contact lenses?

9. Do you have or had you any of the following?

High Blood PressureHeart AttackRheumatic FeverSwollen AnkledFainting/SeizuresAsthmaLow Blood PressureEpilepsy/ConvulsionsLeukemiaDiabetesKidney or HIV InfectionAIDS or HIV InfectionThyroid Problem

8. Women Only:a) Are you pregnant or think you may be pregnant?b) Are you nursing?c) Are you taking birth control pills?

Heart DiseaseCardiac PacemakerHeart MurmurAnginaFrequently TiredAnemiaEmphysemaCancerArthritisJoint Replacement or ImplantHepatitis/JaundiceSexually Transmitted DiseaseStomach Troubles/Ulcers

Chest PainsEasily WindedStrokeHay Fever / AllergiesTuberculosisRadiation TherapyGlaucomaRecent Weight LossLiver DiseaseHeart TroubleRespiratory ProblemsOther

7. Are you allergic to or have you had any reactions to the following?Local Anesthetics (eg. novocaine)Penicillin or other AntibioticsSulfa DrugsBarbituratesSedativesIodineAspirinOther

1. Do your gums bleed while brushing or flossing?2. Are your teeth sensitive to hot or cold liquids/foods?3. Are you teeth sensitive to sweet or sour liquids/foods?4. Do you feel pain to any of your teeth?5. Do you have any sores or lumps in or near your mouth?6. Have you had any head, neck or jaw injuries?7. Have you ever experienced any of the following problems in your jaw? a) Clicking b) Pain (joint, ear, side of face) c) Difficulty in opening or closing? d) Difficulty in chewing?

8. Do you have frequent headaches?9. Do you clench or grind your teeth?10. Do you bite your lip or checks frequently?11. Have you ever had any difficult extractions in the past?12. Have you had any orthodontic work?13. Have you ever had any prolonged bleeding following extractions?14. Have you ever had instruction on the correct method of brushing your teeth?15. Have you ever had instructions on the care of your gums?

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangeorus to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitooners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient or parent if minorDoctor’s Comments:

Signature Date

Yes No

Yes No

Yes No Yes No

Yes No

x

ADHA COVID-19 PATIENT SCREENING QUESTIONNAIRE*indicate Yes or No and provide relevant comments

Do you have a fever or have you felt feverishrecently?

Do you have a cough?

Are you having shortness of breath or anydifficulty breathing?

Do you have chills or repeated shaking withchills?

Do you have any recent onset of headache orsore throat?

Do you have any other flu-like symtoms?

Do you have any recent loss of taste or smell?

Have you experienced any recent GI upset ordiarrhea?

Are you in contact with anyone who has beenconfirmed to be COVID-19 positive?

Have you traveled in the past 14 days to anyregions affected by COVID-19?

Are you over the age of 65?Do you have:Heart diseaseLung diseaseKidney diseaseDiabetesAutoimmune disorders

Patient Name:_____________________________ Date:__________

Screening QuestionsPre-

Appointment*In-

Office*48 Hours Post-Appointment

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Patient’s Communication Method

What do you think about your smile?

How did you hear about us?

Patient’s Name:

Home Phone Number:

Cell Phone Number:

Email Address:

Home Phone NumberCell Phone NumberWork Phone Number

Text MessageEmail AddressNone of the above

Teeth colorTooth ShapeSpaces between teeth

Care to ShareSocial Media Our Website www.dhc.dentalInsurance CompanyFamily or Friend- Name Please:Other:

GoogleZoc DocDemandforce

Alignment of teethSize of TeethGeneral overall appearance of smile

To serve you better, we would like for you to select your appointment confirmation preference. Please check the appropriate form of confirmation desired.

Are you complety satisfied with the cosmetic appearance of your teeth? If not, what concerns do you have?

Which of the following would you change if it could be done easily and pain free?