PEMBROKE PINES DENTAL HEALTH CENTER Welcome

[Pages:6]PEMBROKE PINES DENTAL HEALTH CENTER

Welcome

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us We will be happy to help.

Patient's Information (Confidential)

Name:

Birth Date:

Date: Patient #: S.S #:

Home Phone:

Cell Phone:

E-mail:

Address:

City:

State:

Zip:

Check Appropriate Box: Minor Single Married Divorced Widowed Separated

Patient's or Parent's Employer:

Work Phone:

Business Address:

City:

State:

Zip:

Spouse or Parent's Name:

Employer:

Work Phone:

If Patient is a Student, Name of School/ College:

City:

State:

Zip:

Whom May We Thank for Referring you?

Person to Contact in Case of Emergency:

Phone:

Responsible Party

Name of Person Responsible for this Account:

Relationship to Patient:

Address:

Home Phone:

Driver's License#:

Birthdate:

Financial Institution:

Employer:

Work Phone:

Is this Person Currently a Patient in our Office?

Insurance Information

Name of Insured:

Yes No Relationship to Patient:

Birthdate:

S.S.#:

Date Employed:

Name of Employer:

Work Phone:

Address of Employer:

City:

State:

Zip:

Insurance Company:

Group#:

Union or Local#:

Ins. Co. Address

City:

State:

Zip:

How Much is your Deductible?

How Much Have You Used?

Max. Annual Benefit

Do you have any additional insurance? Yes No

If yes, complete the following:

Name of Insured:

Relationship to Patient:

Birthdate:

S.S.#:

Date Employed:

Name of Employer:

Work Phone:

Address of Employer:

City:

State:

Zip:

Insurance Company:

Group#:

Union or Local#:

Ins. Co. Address

City:

State:

Zip:

How Much is your Deductible?

How Much Have You Used?

Max. Annual Benefit

Over Please

Patient's Medical History

Physician:

Office Phone:

1. Are you under medical treatment now?

Yes No

7. Are you allergic to or have you had any

Yes No

2. Have you ever been hospitalized for any surgical

reactions to the following?

operation or serous illness?

Local Anesthetics (eg. novocaine)

3. Are you taking any medication(s) including

Penicillin or other Antibiotics

non-prescription medicine?

Sulfa Drugs

If Yes, what medication(s) are you taking?

Barbiturates

Sedatives

Iodine

Aspirin

4. Do you use tobacco?

Other

5. Do you use alcohol, cocaine or other drugs?

8. Women Only:

6. Are you wearing contact lenses?

a) Are you pregnant or think you may be pregnant?

b) Are you nursing?

9. Do you have or had you any of the following?

c) Are you taking birth control pills?

Yes No

High Blood Pressure

Heart Disease

Yes No

Chest Pains

Yes No

Heart Attack

Cardiac Pacemaker

Easily Winded

Rheumatic Fever

Heart Murmur

Stroke

Swollen Ankled

Angina

Hay Fever / Allergies

Fainting/Seizures

Frequently Tired

Tuberculosis

Asthma

Anemia

Radiation Therapy

Low Blood Pressure

Emphysema

Glaucoma

Epilepsy/Convulsions

Cancer

Recent Weight Loss

Leukemia

Arthritis

Liver Disease

Diabetes

Joint Replacement or Implant

Heart Trouble

Kidney or HIV Infection

Hepatitis/Jaundice

Respiratory Problems

AIDS or HIV Infection

Sexually Transmitted Disease

Other

Thyroid Problem

Stomach Troubles/Ulcers

Patient's Dental History

Yes No

1. Do your gums bleed while brushing or flossing?

2. Are your teeth sensitive to hot or cold liquids/foods?

3. Are you teeth sensitive to sweet or sour liquids/foods?

4. Do you feel pain to any of your teeth?

5. Do you have any sores or lumps in or near your mouth?

6. Have you had any head, neck or jaw injuries?

7. Have you ever experienced any of the following

problems in your jaw?

a) Clicking

b) Pain (joint, ear, side of face)

c) Difficulty in opening or closing?

d) Difficulty in chewing?

Yes No

8. Do you have frequent headaches? 9. Do you clench or grind your teeth? 10. Do you bite your lip or checks frequently? 11. Have you ever had any difficult extractions in the past? 12. Have you had any orthodontic work? 13. Have you ever had any prolonged bleeding following extractions? 14. Have you ever had instruction on the correct method of brushing your teeth? 15. Have you ever had instructions on the care of your gums?

Authorization and Realease

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangeorus to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitooners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

x

Signature of patient or parent if minor Doctor's Comments:

Signature

Date

ADHA COVID-19 PATIENT SCREENING QUESTIONNAIRE

*indicate Yes or No and provide relevant comments

Patient Name:_____________________________ Date:__________

Screening Questions

PreAppointment*

Do you have a fever or have you felt feverish recently?

Do you have a cough?

Are you having shortness of breath or any difficulty breathing?

Do you have chills or repeated shaking with chills?

Do you have any recent onset of headache or sore throat?

Do you have any other flu-like symtoms?

InOffice*

48 Hours PostAppointment

Do you have any recent loss of taste or smell?

Have you experienced any recent GI upset or diarrhea?

Are you in contact with anyone who has been confirmed to be COVID-19 positive?

Have you traveled in the past 14 days to any regions affected by COVID-19?

Are you over the age of 65? Do you have: Heart disease Lung disease Kidney disease Diabetes Autoimmune disorders

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Give us a review

Patient's Name:

Patient's Communication Method

Home Phone Number:

Cell Phone Number:

Email Address:

To serve you better, we would like for you to select your appointment confirmation preference. Please check the appropriate form of confirmation desired.

Home Phone Number Cell Phone Number Work Phone Number

Text Message Email Address None of the above

What do you think about your smile?

Are you complety satisfied with the cosmetic appearance of your teeth? If not, what concerns do you have?

Which of the following would you change if it could be done easily and pain free?

Teeth color Tooth Shape Spaces between teeth

Alignment of teeth Size of Teeth General overall appearance of smile

How did you hear about us?

Care to Share Social Media Our Website dhc.dental Insurance Company Family or Friend- Name Please: Other:

Google Zoc Doc Demandforce

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