Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information

Transcription

1 Patient Information Please fill this form out completely. Each question is important. If you have any questions please ask. Thank You! Personal Information Today's Date Patient s Name Preferred Name Patient s Birthdate Status: Child / Adult Single Social Security # Married Divorced Widowed Parent s / Spouse s Name (only used to confirm appointments) Billing Home Phone # Cell Phone # Best time to reach you is How do you prefer we contact you? Employment (parent, if patient is a minor) Employer Position Work phone # May we call you at work? What time is best? Spouse s employer Work phone # School Information ( College / University Only ) Student Status: Full time / Part time School Expected date of graduation Student s Local Local telephone # Whom may we thank for referring you! Name Did you hear about us in any other way? Dental Insurance (We d like to photocopy any dental insurance cards you may have.) Employee Name Birthdate Soc.Sec.# Relationship to employee Employer Insurance Company Yearly Benefit $ Deductible $ Secondary Insurance - Employee Name Soc.Sec.# Birthdate Insurance Company Claims Signature on File - The undersigned hereby authorizes the release of any information relating to all claims for benefits on behalf of myself and/or dependants. I further expressly agree and acknowledge that my signature on this document authorizes my dentist to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependants, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I, (name of insured) hereby authorize ( Insurance Company ) to pay and hereby assign to Cowgill Dental all dental benefits, if any, otherwise payable to me for their services as described on the attached forms. I understand I am financially responsible for all charges incurred for the dental treatment provided. Accounts aged over 60 days, interest will be charged at a rate of 1.5% monthly. Signature of Covered Person / Patient (Parent sign for child. Thank you.) Date

2 Health History As a total health-centered practice we are concerned with your total well being. Please answer all questions as completely as possible as all questions have relevance to your oral health. If you have any questions and/or need assistance please feel free to ask. Thank You! Name Today s Date Name of Physician and Clinic Physician s phone Whom may we contact in case of an emergency Contact s Phone Please Circle Answer YES NO Any changes in your health in the past year? If so, how? YES NO Are you currently under the care of a physician? If so, please describe: YES NO Have you ever had any surgical operation of any kind? If so, please describe: YES NO Are you currently taking any medication, prescription or non-prescription? If so, name and dosage: Please write (Y) Yes or (N) No by each medical condition AIDS Excessive Bleeding Liver Disease Ulcers Anemia Fainting Kidney Disease Venereal Disease Arthritis Glaucoma Mental Disorder Cold Sores Artificial Joints Heart Attack Mitral Valve Prolapse Syphilis Asthma Heart Disease MS Herpes Blood Disorders Heart Murmur Nervous Disorders Drug Allergies: Cancer High Blood Pressure Rheumatic Fever Diabetes Hepatitis - Type ( ) Stomach Problems Back Problems Pacemaker Stroke Chemical Dependency Respiratory Problems TMJ Pain (click, pop) Do you Smoke? Dizziness Tuberculosis Epilepsy Latex Allergy Tumors Women Due Date: Are you Nursing? Have you ever taken Antibiotics before dental treatment for cardiac reasons? Have you ever had unfavorable reactions to dental materials? Signature Are you Pregnant? Date

3

4

5