Fill out your health history

Patient Information

Patient Name: Date:
  Last First MI (Preferred Name)  
Gender: Family Status:
Social Security #: Birth Date: E-Mail:
Phone (Home): (Work):
Ext: (Cell):
Preferred appointment times:
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:





























Due date:















List any Medications:


Have you ever had any complications following dental treatment?
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain:
Have you ever had any of the following Cardiac Conditions?
1) Prosthetic cardiac valve.
2) Previous infective bacterial endocarditis.
3) Congenital heart disease (CHD).
4) Cardiac transplant with a later development of cardiac valvulopathy.
Have you had any replacement prosthetic joints or pins in the past two years?
Are you now under the care of a physician?
If yes, please explain:
Name of Physician: Phone:
Do you have any health problems that need further clarification?
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?
Name of person or office referring you to our practice:


Spouse or Responsible Party Information

The following is for:
Name:


Social Security #:
Birth Date:
Phone (Home):
(Work):
Ext:
Best time to call:
Address:


Employment Information

The following is for:
Employer Name:
Occupation:
Address:


Insurance Information

Primary
Name of Insured:
Is insured a patient?
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Patient's relationship to insured:
Insurance Plan Name and Address:
Secondary
Name of Insured:
Is insured a patient?
Insured's Birth Date: ID #: Group #:
Insured's Address:
Insured's Employer Name:
Patient's relationship to insured:
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

website by website designers nj samsonmedia.net