| Patient Health and Dental History Name: _______________________________________________________ Today's Date: _________________ Address: _____________________________________________ City____________________ Zip___________ Home Ph: ______________________Cell Ph: ________________________ Work Ph: _____________________ Date of Birth: __________________ SS# ____________________ E-Mail: _______________________________ Person responsible for this account: ________________________________________Relationship: _________________ HOW DID YOU HEAR ABOUT OUR OFFICE: __________________________________________________ INSURANCE INFORMATION: Dental Insurance Company __________________________ Group # __________________________ Subscriber: __________________________________ Employer: ___________________ Sub. Ins. ID# _______________________ Subscriber SS# _________________________ Date of Birth: ____________________ Relationship to Patient: _________________ __________________________________________________________________________________________________________ MEDICAL INFORMATION Are you currently under a doctors care? Y / N Condition:_____________________________________________________________ Name of your physician? ______________________________________________ Phone# ________________________________ Are you presently taking medication? Y / N Please list all medications and reasons for taking them: ___________________________ __________________________________________________________________________________________________________ Are you allergic to any medication? Y / N Please list: _______________________________________________________________ Have you ever been told that you need to take an antibiotic prior to dental treatment? Y / N What Kind? __________________________ BELOW: PLEASE CIRCLE ALL CONDITIONS THAT APPLY TO YOU: Women: Are you pregnant? Y / N Using oral contraceptives? Y / N Do you have any other medical conditions or concerns that you think we should be made aware of? _____________________________________________________________________________________________________________ |
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| DENTAL HISTORY Do you have any fears towards dental treatment? ___________________________________________________ Do you have discomfort eating or drinking: COLD: Y / N HOT: Y / N SWEETS: Y / N Have you had your wisdom teeth removed? Y / N Do you clench or grind your teeth? Y / N Do you have clicking, popping or pain in your jaw? Y / N Do you believe or have you been told that you have bad breath? Y / N Do you feel that your teeth are moving or getting longer? Y / N Are you embarrassed to smile in public or in pictures? Y / N Do you wish that your teeth were (circle ALL that apply) Straighter Whiter Prettier Less Gaps Smaller Bigger Less Silver On a scale of 1 to 10: How important is a beautiful smile to you? _________ How important is it to keep your own teeth throughout your lifetime? _________ Are there any dental problems or concerns not addressed on this form that you would like to discuss with the dentist? __________________________________________________________________________________________________________ PLEASE READ, SIGN AND DATE THE SECTION BELOW: Notice of Privacy Practices: I understand that understand that under the Health Insurance Portability Accountability Act (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct , plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly. It may be used to obtain third party payers and to conduct normal health care operations such as quality assessments and physician certifications. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may at any time obtain a current copy of such. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name (Print): _________________________________________________________ Relationship: ______________________ Signature: _________________________________________________________________ Date: ________________________ _____________________________________________________________________________________________________________________________ PLEASE READ, SIGN AND DATE THE SECTION BELOW: I give permission for treatment to be performed for myself or my dependant child at this visit or at future visits. I hereby authorize any provider, insurer or other organization to release any information regarding the dental history or treatment, or benefits payable for said claim of the plan administrator or its authorized agent for the purpose of determining benefits payable. I understand that occasionally Dr. Lawrence will find that additional dental treatment will be necessary and cannot be exactly determined prior to proceeding with treatment. I understand that my insurance payments and my out of pocket amounts will be estimated prior to starting treatment and are subject to change. I understand that I am fully responsible for all remaining balances. I understand that I am financially responsible for the care provided and that any insurance is considered a method of reimbursement but is NOT a substitution for payment. I authorize my signature to be 'on file' for the processing of dental claims on my or my family's behalf and authorize benefits to be paid directly to Stephen M. Lawrence DMD. I understand that deductibles, co-payments and non covered services are my responsibility to pay at the time of service unless other arrangements have been made. I understand that as a courtesy to me, Dr. Lawrence will pursue all insurance claims up to 60 days at which time I am fully responsible for this account. Patient Name (Print): _________________________________________________________________________ Patient or Parent/Guardian Signature: ____________________________________________________________ Date: _____________________ We look forward to meeting you! |
