Welcome
1 About You
Patient Name
Status
Do you have kids?
2 Insurance Info.

Primary Dental Insurance

Secondary Dental Insurance

3 Account Info

Person ultimately responsible for account

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid for by my insurance company (if offered at this office).

4 In Event Of Emergency
Medical Information
What is your estimate of your general health?
Do You Have or Have You Ever Had:
YesNo
1.
hospitalization for illness or injury
2.
an allergic or bad reaction to any of the following:
)
YesNo
3.
heart problems or cardiac stent within the last six months
4.
history of infective endocarditis
5.
artificial heart valve, repaired heart defect (PFO)
6.
pacemaker, implantable defibrillator, or organ transplant
7.
orthopedic or soft tissue implant (e.g., joint replacement)
8.
heart murmur, rheumatic or scarlet fever
9.
high or low blood pressure
10.
a stroke (taking blood thinners)
11.
anemia or other blood disorder
12.
prolonged bleeding due to a slight cut (or INR > 3.5)
13.
pneumonia, emphysema, shortness of breath, sarcoidosis
14.
chronic ear infections, tuberculosis, measles, chicken pox
15.
breathing problems (e.g., asthma, nasal breathing, stuffy nose, sinus congestion)
16.
sleep problems (e.g., sleep apnea, snoring, insomnia, restless sleep, bedwetting)
17.
kidney disease
18.
liver disease or jaundice
19.
vertigo (e.g., "the room is spinning")
20.
thyroid, parathyroid disease, or calcium deficiency
21.
hormone deficiency or imbalance (e.g., polycystic ovarian syndrome)
YesNo
22.
high cholesterol or taking statin drugs
23.
diabetes (HbA1c = )
24.
stomach or duodenal ulcer
25.
digestive or eating disorders (e.g., gastric reflux, bulimia, anorexia, celiac disease, Crohn's disease, or any inflammatory bowel disease)
26.
osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g., bisphosphonates)
27.
arthritis or gout
28.
autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)
29.
glaucoma
30.
contact lenses
31.
head or neck injuries
32.
epilepsy, convulsions (seizures)
33.
neurologic disorders (e.g., Alzheimer's disease, dementia, prion disease)
34.
viral infections (e.g., cold sores) bacterial infections (e.g., Lyme disease)
35.
any lumps or swelling in the mouth
36.
hives, skin rash, hay fever
37.
STI/STD/HPV
38.
hepatitis (type )
39.
HIV/AIDS
40.
tumor, abnormal growth
41.
radiation therapy
42.
chemotherapy, immunosuppressive medication
43.
difficulties with stress management
44.
psychiatric treatment, antidepressants, mood stabilizing medications
45.
concentration problems or ADD/ADHD
46.
alcohol/recreational drug use
Are You:
YesNo
47.
presently being treated for any other illness
48.
aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
49.
taking medication for weight management
50.
taking dietary supplements, vitamins, and/or probiotics
51.
often exhausted or fatigued
52.
experiencing frequent headaches or chronic pain
53.
a smoker, smoked previously or other (e.g., smokeless tobacco, vaping, e-cigarettes, and cannabis)
54.
considered a touchy/sensitive person
55.
often unhappy or depressed
56.
taking birth control pills
57.
currently pregnant or breastfeeding
58.
diagnosed with a prostate disorder
List all medications, supplements, vitamins, and/or probiotics taken within the last two years.
Drug
Purpose
Drug
Purpose
Please advise us in the future of any change in your medical history or any medications you may be taking.
CONSENT:
  1. The undersigned hereby authorizes to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient's dental needs.
  2. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using mechanical delivery with anesthetic agents, and/or nitrous oxide analgesia embodies a certain risk, which may include swelling, pain, trismus (restricted jaw opening), infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent. I understand that it is my responsibility to report any symptoms to the dentist. Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment.
  3. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1 - 1/2 % finance charge (18% APR) may be added to my account, in addition to any collection charges.
  4. I have received a copy of the Dental Materials Fact Sheet and a copy of the HIPAA Privacy Policy as required by law.
  5. I grant the right to the dentist to release my dental/medical and other information about my dental treatment to third party payors and/or other health professionals, as appropriate under the circumstances.
  6. I grant the dental office permission to use the email address given above to contact me with respect to my dental care.
FOR OFFICE USE: