Patient Information
Patient Information
Patient Name: _______________________________________________________ Date: ___________________
Gender: _______________ Family Status: ______________
Social Security #: _______________________________ Birth Date: ____________________________________
Phone (Home): _____________________ (Work): _____________________ (Cell) ________________________
Address: _______________________________________City,State,Zip__________________________________
Email: ______________________________________________________________________________________
How would you like to receive appointment reminders? (Please circle all that apply)
Home Work Email Cell Text
Employer____________________________________ Occupation_________________________________________
Business address__________________________________ City,State,Zip_______________________________________
Person financially responsible_________________________________________Phone____________________________
How were you referred to this office? ____________________________________________________________________
Emergency Contact Information
Emergency Contact Person _______________________________________Relationship ____________________
Phone ____________________________________ (Other) ___________________________________________
Insurance
If you have dental insurance please present your card at the time of your appointment.
We will be happy to submit your insurance claims as a courtesy. Please realize that your insurance is a contract between you, your employer, and your insurance company. Our relationship is with you and not your insurance company. Each insurance company is different and it is your responsibility to understand your dental benefits. All financial charges are your responsibility.
Cancellation policy: We require 24 hours notice for cancellation. If less than 24 hours notice, a $50.00 charge may be applied to your account.
Name:
Medical Information
Have you ever had any of the following? Please check those that apply:
( AIDS ( Chest Pains ( Heart Attack ( Mitral Valve Prolapse
( Alcoholism ( Cold Sores ( Heart Condition ( Psychiatric Treatment
( Anemia ( Cortisone Medicine ( Heart Murmur ( Radiation Therapy
( Anxiety ( Diabetes ( Heart Pacemaker ( Rheumatic Fever
( Arthritis ( Difficulty Swallowing ( Heart Surgery ( Skin Rashes or Hives
( Artificial Heart Valve ( Dizziness ( Hepatitis A (infectious) ( Stroke
( Artificial Joints ( Drug Addiction ( Hepatitis B (serum) ( Swelling of Ankles
( Asthma ( Dry Mouth ( High Blood Pressure ( Thyroid Disease
( Blood Disease ( Emphysema ( Jaundice ( Tuberculosis (T.B.)
( Blood Transfusion ( Epilepsy ( Kidney Trouble ( Venereal Disease
( Bruise Easily ( Eye Disease ( Liver Disease ( Cancer ( Fainting ( Lung Disease ( Chemotherapy ( Head Injuries
Are you now or do you anticipate becoming pregnant? __________________ If yes, due date: ________________________
Are you currently taking birth control? _______________________________ If yes, prescription: _____________________
Do you have any diseases, conditions, or problems not listed above?
If yes, please explain __________________________________________________________________________________
____________________________________________________________________________________________________
Have you ever been hospitalized or had a serious illness in the last three years? If yes, indicate why:
____________________________________________________________________________________________________
Are you being treated by a physician now? If yes, please explain:
____________________________________________________________________________________________________
Name of Physician: ______________________________________________ Phone: _______________________________
Do you have a persistent sore throat, hoarseness, earache, or feeling of something being caught in your throat? (If yes, please explain.)____________________________________________________________________________________________
Do you now or have you in the past smoked or used tobacco? __________________________________________________
Please list any current medication and/or drugs you are taking (please include any non-prescription vitamins & health supplements)(Use back of page or attach list if needed)
________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any medications, drugs, and/or substances you have become sick from or have shown an allergic reaction to:_____________________________________________________________________________________________________________________________________________________________________________________________________
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 doctor at the next appointment without fail.
_______________________________________________________________________ Date: _______________________
Signature of patient, parent or guardian
Medical History Update
Date Addition
___________ __________________________________________________________________________________________________
___________ __________________________________________________________________________________________________
___________ __________________________________________________________________________________________________
Dental History
Do you have any current dental problems? _________________________________________________________
Are you in pain now? __________________________________________________________________________
Date of last complete dental examination __________________________________________________________
Are you teeth sensitive to cold or sweets? __________________________________________________________
Do your gums bleed easily when you brush or floss? _________________________________________________
Have you noticed that your gums are red, swollen, or tender? __________________________________________
Do you ever have a bad taste in your mouth soon after brushing you teeth? _______________________________
Have you noticed any loose teeth or change in your bite? _____________________________________________
Do you grind your teeth? _______________________________________________________________________ Do you snore or ever been told you have sleep apnea? ________________________________________________
Have you ever had orthodontic appliances (braces)? _________________________________________________
Have you ever had gum (periodontal) surgery? _____________________________________________________
Have you ever had clicking or popping in your ears when you chew? ____________________________________
Have you ever had an injury to your face, neck or jaw? _______________________________________________
Are you happy with your smile? _________________________________________________________________
If not, what would you change? __________________________________________________________________
Are you interested in whitening your teeth? ________________________________________________________
Do you feel nervous about having dental treatment? _________________________________________________
Have you ever had any problems with prior dental treatment? __________________________________________
Have you ever had an unfavorable experience from local anesthetics? ___________________________________
Tell us, in your opinion, what you think the present state of health your mouth is in? _____________________
___________________________________________________________________________________________
How healthy do you want us to get your mouth? (please circle)
a) Don’t really care b) Average c) The best it can be!
Should you need treatment, at what point should we address it? (please circle)
a) When my tooth hurts or breaks b) When something is worsening c) When something is not ideal
What quality of dentistry do you want us to recommend? (please circle)
a) Just patch it b) Average c) Ideal, the best
Consent for Services
I hereby authorize doctor or designated staff to administer dental treatment and local anesthetic and to perform procedures deemed appropriate to make a thorough diagnosis.
I further authorize Dr. Paul Glass to perform all recommended treatment mutually agreed upon by me and employ such assistance as required to provide proper care.
I hereby assign Dr. Paul Glass benefits which are due or are to become due as a result of dental services rendered. I hereby authorize that payments be made directly to Dr. Paul Glass.
I agree to be responsible to payment of all services on my behalf or my dependents. I understand that payment is due at time of service unless other arrangements have been made.
We request your permission to show any of your photographs or x-rays to better explain treatment options to other patients (as you will be shown photos and x-rays for the same reason). We would also request your permission to post before and after photos on our website (no full names will be used). If you would like to opt out of the this, please put an “X” through the number “ 5.” Thank you.
_________________________________________________________ Date: ___________________Relationship to Patient: _____________________
Signature of patient, parent, or guardian
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