1 About You
Patient Name
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
1. Are you having any pain or discomfort at this time?
2. Have you been a patient in the hospital during the last two years?
3. Are you now taking any medication or drugs?
4. A. Have you taken any medication or drugs during the last two years?
B. Have you ever taken appetite suppressants i.e. fen-phen (Fenfluramine & Phentermine) or dexfenfluramine or fenfluramine?
5. Have you been under the care of a medical doctor during the last two years or since, taking the appetite suppressant named above?
6. Are you sensitive or allergic to any medications or anesthetics?
7. Indicate which of the following you have had or have at the present. Check "yes or no" to each item.
Allergies or Hives
Allergy to Latex
Allergy to Metal (jewelry, etc.)
Angina Pectoris
Artificial Heart Valve
Artificial Joints (hip, knee, etc.)
Blood Transfusion
Bruise Easily
Cancer History
Chronic Cough
Cold Sores/Fever Blister
Congenital Heart Disease
Cortisone Medicine
Developmentally Disabled
Drug Addiction
Fainting or dizzy spells
H.I.V. Positive
Hay Fever
Heart Disease or Attack
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Surgery
Hepatitis A (Infectious)
Hepatitis B (Serum)
High Blood Pressure
Kidney Trouble
Liver Disease
Mitral Valve Prolapse
Radiation Therapy
Rheumatic Fever
Sickle Cell Disease
Sinus Trouble
Thyroid Problems
Venereal Disease
Yellow Jaundice
8. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired?
9. Do you ever wake up from sleep and feel short of breath?
10. Have you lost or gained more than ten pounds in the past year?
11. Are you on a special diet?
12. Do you have or have you had any disease, condition, or problem not listed?
13. Do your ankles swell during the day?
14. Do you use more than two pillows to sleep?
Are you pregnant?
Are you nursing?
Are you taking birth control pills?
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. I understand that it is my responsibility to advise your office of any changes in the information obtained on this form.
  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.