New Patient Form - Fountain Hills Dentist
Transcription
New Patient Form - Fountain Hills Dentist
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. lf you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health. Name Last Name Soc. Sec. # First Name Address City Email Cell Sex Home Phone Zip State lM JF Age Birthdate J Single tr Married J Widowed J Separated I - Patient Employed by Divorced "_d x* Occupation Business Phone Business Address Business Email Whom may we thank for referring you? Notify in case of emergency Home Phone Cell Phone Work Phone Email Person Responsible for Account Relation to Patient Soc. Sec. # Birthdate Address (if different from patient) lnitial First Name Last Name Home Phone City Zip State - Cell Phone Email Person Responsible Employed by Occupation Business Address - Business Email Business Phone lnsurance Company lnsurance Email Contract # Subscriber # Group # Name of other dependents under this plan ls patient covered by additional insurance? tr Yes O No Flelation to Patient Subscriber Name Address (if different from patient) Birthdate Soc. Sec. # City Home Phone State - Cell Phone Email -Zp Subscriber Employed by Business Phone Business Email Phone lnsurance Company .':: lnsurance Email Contract # Group # Subscriber # Name of other dependents under this plan ru . i .-l ':.- .:: :i: rt w l ij ,.8' Are you in dental discomfort today? What would you like us to do today? Former Dentist Phone Address Dentist's Email Date of last dental care Date of last x-rays Check ( / ) it you have had problems with any of the following: lYlNBadbreath j tr N Bleedinggums 1!ffi AV iffi O" tr N Clickingorpopping jaw I Y I N Food collection between teeth DY trN trY trN Grindingorclenchingteeth Looseteethorbrokenlillings I Y -.1 N Periodontal treatment I Y -l N Sensitivity to cold lY lNSensitivitytohot How often do you brush? ,!ry& lY I :JY 'J I Y -l N Sensitivity to sweels N Sensitivity when biting N Sores or growths in mouth Floss? How do you feel about the appearance of your teeth? Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? I Y :l N Other information about your dental health or previous treatment s,*.;sa." .n, *.:.-"r. = Physician's name Phone Have you had any serious illnesses or operations? Date of last visit I Y -l N lf yes, describe Are you currently under physician care? Have you ever had a blood transfusion? Have you ever taken Fen-Phen/Redux? -i! S I'er r,$_3 I Y -l N fYI N tr Y I N lf yes. describe lf yes, give approximate dates Have you ever used a bisphosphonate medication? arano Women: Areyoupregnant? Check ( / trY trN Nursing? names include Fosamax, Actonel, Atelvia, Didronel and DY trN Takingbirthcontrol pills? trY Boniva. tr Y tr N trN ) yes or no whether you have had any of the following: :l Y -l N Cough, persistent JYIN -l Y :l N Cough up blood -lY J N JY JN Blooddisease Describe JY J N Cancer fYIlN Chemical dependency lYlN Hemophilia/ Abnormal bleeding JY -.1 N Chemotherapy Herpes -lY J N Circulatoryproblems ]Y I I lY I N Hepatitis ly f, N cortisone treatments I Y -l N High blood pressure lYf N Shingles Jawpain Kidneydiseaseor lY I N Shortnessof breath mal{unction Jy_lN Skinrash -lYlN Liverdisease JylN SpinaBifida lYlN Material allergies lylN Stroke (latex, wool, metal, ly I N Surgical implant chemicals) r y r N Mirrar varve prorapse -IY -l N ],.*;l'[Sr"t ** -lY I N Nervous problems ly l N Thyroiddiseaseor lYlN Pacemaker/ mallunction Heartsurgery lYlN Tobaccohabit lY -lN Psychiatriccare Jy lN Tonsillitis I Y -J N Rapid weight gain or loss I y f N Tubercutosis JY J N Radiationtreatment ly I N Ulcer/Cotitis lY I N Respiratorydisease Jy _l N Venereal disease -l Y -l N Rheumatrc/Scarlet fever ls patient currently taking any medications? lf yes, list all: Does patient have drug allergies? lf yes, list all: trY lN AIDS/HlVPositive UY aN Anaphylaxis trY a N Anemia lY I N Arthritis, Rheumatism J Y -l N Artificial heart valves I Y :l N Artif icial joints lY -l N Asthma lY J N Atopic (allergy prone) lY -l N Back problems trY lN JY -l N -l Y J N -lY JN -lY lN Diabetes Epilepsy Fainting Foodallergies Giaucoma Headaches lY I N DY trN Heartmurmur BY DN Heartproblems AuSho:"EeqfEon I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. lf there is any change in my medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. Date Signature Payment is due in full at time of treatment, unress prior arrangements have been approved. osmailPractice@ ,.g': *80,785 All rights reserved. :. R1