Fill out your health history

Patient Information

Patient Name:

Date:

Last

First

(Preferred Name)

Gender:

Family Status:

Social Security #:

Birth Date:

E-Mail:

Phone (Home):

(Work):

Ext:

(Cell):

Preferred appointment times:

Morning

Afternoon

Evening

Any Time

Address:

Street

Apartment #


City	State	Zip Code

Health Information

Date of Last Dental Visit: Reason for this visit:
Have your ever had any of the following? Please check those that apply:
AIDS
Allergies

Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Pregnancy
Due date:
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease
Codeine Allergy
Penicillin Allergy
OTHER:

List any Medications:

Have you ever had any complications following dental treatment? Yes No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
If yes, please explain:
Have you ever had any of the following Cardiac Conditions?
1) Prosthetic cardiac valve. Yes No
2) Previous infective bacterial endocarditis. Yes No
3) Congenital heart disease (CHD). Yes No
4) Cardiac transplant with a later development of cardiac valvulopathy. Yes No
Have you had any replacement prosthetic joints or pins in the past two years? Yes No
Are you now under the care of a physician? Yes No
If yes, please explain:
Name of Physician: Phone:
Do you have any health problems that need further clarification? Yes No
If yes, please explain:
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Date:
Signature of patient, parent or guardian

Referral Information

Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative Dental Office Yellow Pages Newspaper School Work Other
Name of person or office referring you to our practice:

Spouse or Responsible Party Information

The following is for: the patient's spouse the person responsible for payment
Name:
Male Female
Married SingleChild Other
Social Security #:
Birth Date:
Phone (Home):
(Work):
Ext:
Best time to call:
Address:

Employment Information

The following is for: the patient the person responsible for payment
Employer Name:
Occupation:
Address:

Insurance Information

Primary
Name of Insured:
Is insured a patient? Yes No
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Patient's relationship to insured: Self SpouseChild Other
Insurance Plan Name and Address:
Secondary
Name of Insured:
Is insured a patient? Yes No
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Patient's relationship to insured: Self SpouseChild Other
Insurance Plan Name and Address:

Consent for Services

-As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
-All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
-Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
-A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. In addition, if collection proceedings become necessary, a 40% collection fee will be added to the balance of the account.
-I understand that the fees estimated for dental care can only be extended for a period of three months from the date of the patient examination.
-In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
-I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
-I have read the above conditions of treatment and payment and agree to their content.
Date: Relationship to Patient:
Signature of patient, parent or guardian
Date: Relationship to Patient:
Signature of guarantor of payment/responsible party

Patient Guide Information

	Appointment Request Form			Office Policy
	Smile Evaluation			Privacy Policy

Contact Info

347 Valley Road	E-mail: lduca@ducadentistry.com
Clifton, NJ 07013	Phone: 973.278.8181

website by website designers nj samsonmedia.net