Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
W E L C 0 M EPATIENT INFORMATION DENTAL INSURANCEDale Who is responsible for this account?
SSN/HIC/Patient 10# Relationship to patient
, -Patient Insurance Co.
Address Group #
City Is patient covered by additional insurance? OVes ONo
State Zip Subscriber's Name
E-mail Birthdate SSN#
Sex OMaie o Female Age Relationship to Patient
Birthdate Insurance Co.
oMarried oWidowed oSingle oMinor Group #
oSeparated o Divorced oPartnered for ___ Vrs. ASSIGNMENTAND RelEASEI certify that I, and/or my dependent(s), have insurance coverage
Occupationwith:
Patient Employer/Schooland assigndirectly to Dr.
Employer/School Address all insurance benefits, if any, otherwise payable to me forservices rendered. I understand that I am financiallyresponsible for all charges whether or not paid by insurance. Iauthorize the use of my signature on all insurance forms.
Employer /School Phone (----.l .The above named doctor may use my health care information and
Spouse's Name may disclose such information to the above-named InsuranceCompany(ies) and their agents for the purpose of obtaining
Birthdate payment for services and determining insurance benefits or thebenefits payable for related services. This consent will end when
SSN# my current treatment plan is completed or on year from the datesigned below.
Spouse's Employer
Whom may we thank for referring you? Signature of Patient, Parent, Guardian or Personal Representative
How did you hear about us?Pleaseprint name of Patient, Parent, Guardian or Personal Representativeo Radio oWebsite o Friend o Relative
oOther Date Relationship to Patient
PHONE NUMBERSHome ( ) Work~ Ext Cell Phone (----.l
Spouse's Work ( ) Best time and place to reach you
IN CASEOF EMERGENCY,CONTACT(Specify someone who does not live in your household.)
Name Relationship
Home Phone ( ) Work Phone ( )
DENTAL HISTORY
Reason for today's visit Burning sensation on tongue OVes ONo Mouth Breathing OVes ONoChew on one side of mouth OYes ONo Mouth pain, brushing oYes ONoCigarette, pipe, or cigar smoker OYes ONo Orthodontic treatment oYes ONo
Former Dentist Clicking or popping jaw OYes ONo Pain around ear oYes ONoDry Mouth OYes ONo Periodontal treatment oYes ONo
City/State Fingernail biting OVes ONo Sensitivity to cold oYes ONoFood collects between teeth OYes ONo Sensitivity to heat OVes ONo
Date last dental visit Foreign objects OYes ONo Sensitivity to sweets oYes ONoGrinding teeth OYes ONo Sensitivity when biting OVes ONo
Date last dental x-rays Gums swollen or tender OYes ONo Sores in mouth oYes ONoJaw pain or tiredness OYes ONo
Place a mark on "yes" or "no" to indicate if Lip or cheek biting OYes ONo How often do you floss?you have had any of the following: Loose teeth or broken fillings OYes ONoBad Breath OYes ONo How often do you brush?Bleeding gums OYes ONoBlisters on lips or mouth OYes ONo
HEALTH HISTORY
Physician's Name Date of last dental visitHave you ever taken ahy of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names ofPhentermine), Podimin (fenfluramine) and Redux (dexfenfluramine). 0Yes ONoPlace a mark on "yes" or "no" to indicate if you have had any of the following:
, -AIDS/HIV OVes ONo Epilepsy OVes ONo Respiratory Disease OVes ONo
Anemia OVes ONo Fainting or dizziness OVes ONo Rheumatic Fever OVes ONoArthritis, Rheumatism OVes ONo Glaucoma OVes ONo Scarlet Fever OVes ONoArtificial Heart Valves OVes ONo Headaches OVes ONo Shortness of Breath OVes ONoArtificial Joints OVes ONo Heart Murmur OVes ONo. Sinus Trouble OVes ONo
Asthema OVes ONo Heart Problems OVes ONo Skin Rash OVes ONo
Back Problems OVes QNo Hepatitis Type __ OVes ONo Special Diet OVes ONo
Bleeding abnormally, with OVes ONo Herpes OVes ONo Stroke OVes ONo
Extractions or surgery OVes ONo High Blood Pressure OVes ONo Swollen Feet or Ankles OVes ONoBlood Disease OVes ONo Jaundice OVes ONo Swollen Neck Glands OVes ONoCancer OVes ONo Jaw Pain OVes ONo Thyroid Problems OVes ONo
Chemical Dependency OVes ONo Kidney Disease OVes ONo Tonsillitis OVes ONoChemotherapy OVes ONO liver Disease OVes ONo Tuberculosis OVes ONoCirculatory Problems OVes ONo Low Blood Pressure OVes ONo Tumor or growth on head/neck OVes ONoCongenital Heart Lesions OVes ONo Mitral Valve Prolapse OVes ONo Ulcer OVes ONoCortisone Treatments OVes ONo Nervous Problems OVes ONo Veneral Disease OVes ONoCough, Persistent or bloody OVes ONo Pacemaker OVes ONo Weight Loss,unexplained OVes ONoDiabetes OVes ONo Psychiatric Care OVes ONoEmphysema OVes ONo Radiation Treatment OVes ONo
Do vou wear contact lenses? OVes ONO
Women:Are you Pregnant? OVes ONO Due Date Are you nursing? OVes ONo ,
MEDICAnONS ALLERGIESlist any medications you are currently taking and the correlating oAspirin o Local Anestheticdiagnosis:
o Barbiturates (sleeping pills) o Penicillin
oCodeine oSulfa
Pharmacy Name o Iodine oOther
Phone(~ o Latex
UPDATES (Tobe filled in at future appointments)
Has there been any change in your health since your last dental appointment? o Yes ONo
For what conditions?
Are you taking any new medications? If so, what?
Patient's Signature Date
Doctor's Signature Date
Has there been any change in your health since your last dental appointment? OVes ONo
For what conditions?
Are you taking any new medications? If so, what?
Patient's Signature Date
Doctor's Signature DateHas there been any change in your health since your last dental appointment? OVes ONo
For what conditions?
Are you taking any new medications? If so, what?
Patient's Signature Date
Doctor's Signature Date