Name: ______________________________ Home Phone ...



DENTAL INFORMATION AND HISTORY

Reason for today’s visit _______________________ How do you feel about the appearance of your teeth?

____________________________________________ ______________________________________________

Former dentist _______________________________ _______________________________________________

____________________________________________ _______________________________________________

City/ State __________________________________ Have you ever had whitening treatments? ___________

Date of last dental visit _______________________ _______________________________________________

Date of last dental x-rays _____________________ Is there anything you’d like to change about your teeth,

How would you describe your current dental condition? if so, when is your deadline (wedding, prom photos

____________________________________________ etc)?__________________________________________

____________________________________________ ______________________________________________

Place a mark on “yes” or “no” to indicate if you have had any of the following:

Bad breath □ Yes □ No Lip or cheek biting □ Yes □ No

Bleeding gums □ Yes □ No Loose teeth or broken fillings □ Yes □ No

Blisters on lips or mouth □ Yes □ No Mouth breathing □ Yes □ No

Burning sensation on tongue □ Yes □ No Mouth pain, brushing □ Yes □ No

Chew on one side of mouth □ Yes □ No Orthodontic treatment □ Yes □ No

Cigarette, pipe or cigar smoking □ Yes □ No Pain around ear □ Yes □ No

Clicking or popping jaw □ Yes □ No Periodontal treatment □ Yes □ No

Dry mouth □ Yes □ No Fingernail biting □ Yes □ No

Food collection between the teeth □ Yes □ No Foreign objects □ Yes □ No

Grinding teeth □ Yes □ No Gums swollen or tender □ Yes □ No

Jaw pain or tiredness □ Yes □ No Sensitivity to cold □ Yes □ No

Sensitivity to heat □ Yes □ No Sensitivity to sweets □ Yes □ No

Sensitivity when biting □ Yes □ No Sores or growths in your mouth □ Yes □ No

Snoring □ Yes □ No

How often do you brush? _______________________ How often do you floss?________________________

MEDICAL INFORMATION

Primary Physician’s Name: ______________________________ Date of last visit: __________________

Place a mark on “yes” or “no” to indicate if you have had any of the following:

AIDS/HIV □ Yes □ No Anemia □ Yes □ No

Acid reflux/GERD □ Yes □ No Artificial Heart Valves □ Yes □ No

Arthritis/Rheumatism □ Yes □ No Asthma □ Yes □ No

Artificial Joints □ Yes □ No Blood Disease □ Yes □ No

Back Problems □ Yes □ No Chemical Dependency □ Yes □ No

Cancer □ Yes □ No Circulatory Problems □ Yes □ No

Chemotherapy □ Yes □ No Cortisone Treatments □ Yes □ No

Congenital Heart Lesions □ Yes □ No Diabetes □ Yes □ No

Cough, persistent or bloody □ Yes □ No Epilepsy □ Yes □ No

Emphysema □ Yes □ No Glaucoma □ Yes □ No

Fainting or dizziness □ Yes □ No Osteoporosis □ Yes □ No

Headaches □ Yes □ No Heart Murmur □ Yes □ No

Heart Problems □ Yes □ No Hepatitis Type ______ □ Yes □ No

Herpes □ Yes □ No High Blood Pressure □ Yes □ No

Jaundice □ Yes □ No Jaw Pain □ Yes □ No

Kidney Pain □ Yes □ No Liver Disease □ Yes □ No

Low Blood Pressure □ Yes □ No Mitral Valve Prolapse □ Yes □ No

Nervous Problems □ Yes □ No Pacemaker □ Yes □ No

Psychiatric Care □ Yes □ No Radiation Treatment □ Yes □ No

Respiratory Disease □ Yes □ No Rheumatic Fever □ Yes □ No

Scarlet Fever □ Yes □ No Shortness of Breath □ Yes □ No

Sinus Trouble □ Yes □ No Skin Rash □ Yes □ No

Special Diet □ Yes □ No Stroke □ Yes □ No

Swollen Feet or Ankles □ Yes □ No Swollen Neck Glands □ Yes □ No

Thyroid Problems □ Yes □ No Tonsillitis □ Yes □ No

Tuberculosis □ Yes □ No Tumor or Growth on Head/Neck □ Yes □ No

Ulcer □ Yes □ No Venereal Disease □ Yes □ No

Weight Loss Unexplained □ Yes □ No

Eating Disorders: Bulimia, have your teeth been affected? _________ Anorexia □ Yes □ No

Neurological Disorders: _____________________________________________________________________________

Sexually Transmitted Diseases: _______________________________________________________________________

Mental Health Disorders: ____________________________________________________________________________

Women: Are you or could you be pregnant? □ Yes □ No Due Date: ____________________

Are you nursing? □ Yes □ No

Taking birth control pills? □ Yes □ No

MEDICAL INFORMATION (continued)

MEDICATIONS ALLERGIES

Please list any medications you are taking □ Aspirin □ Local Anesthetic

and the correlating diagnosis: □ Penicillin □ Codeine

_______________________________ □ Sulfa □ Iodine

__________________________________ □ Latex □ Metals

_______________________________ □ Avocado □ Barbiturates (sleeping pills)

_______________________________ □ Food (specify) ___________________________

_______________________________ □ Animals (specify) ________________________

_______________________________ □ other Antibiotics _________________________

_______________________________ □ other Narcotics __________________________

Pharmacy Name: ________________________________________ Phone# ___________________________

Is there any other information you would like Great Smiles of Elizabeth to know? ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

I UNDERSTAND THAT MY MEDICAL HISTORY MAY DETERMINE TREATMENT OPTIONS AND MEDICATIONS USED. I WILL NOT HOLD MY DENTIST OR ANY OTHER MEMBER OF HIS/HER STAFF RESPONSIBLE FOR ANY ACTION THEY TAKE OR DO NOT TAKE BECAUSE OF ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.

___________________________________________________ _________________________________________

Patient’s (Guardian’s) Signature Date

-----------------------

Medical Update

FINANCIAL INFORMATION

Who is responsible for this account?

________________________________________

Relationship to patient: _____________________

Do you have dental insurance? YES NO

Name of Insurance Company: ________________________________________

Is the patient the member/subscriber? YES NO

Name of Subscriber: ______________________

Subscriber ID/ SS# _______________________

Subscriber Date of Birth: __________________

Is the patient covered under another dental insurance?

YES NO

Name of Secondary Insurance Company:

________________________________________

Name of Subscriber: _______________________

Subscriber ID/ SS# ________________________

Subscriber Date of Birth: ___________________

I certify that I, and/or my dependent (s), have insurance coverage with ____________________ (name of insurance company) and assign directly to Great Smiles of Elizabeth, LLC all insurance benefits, if any. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Great Smiles of Elizabeth, LLC may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end 1 year from the date signed below.

PATIENT INFORMATION

Patient Name: _____________________________

Name preferred to be called: __________________

Date of Birth: __________ Sex: Male Female

Social Security # ___________________________

Home Phone: _____________________________

Work Phone: _____________________________

Cellular Phone: ____________________________

Email Address: _____________________________

Address: _________________________________

Apt: __________ City _______________________

State: __________________ Zip Code: _________

Patient Employer/School: ____________________

Occupation: _______________________________

Emergency Contact: ________________________

Relationship to patient: ______________________

Phone Number: ____________________________

Whom may we thank for referring you to our office?

__________________________________________

APPOINTMENT CONFIRMATION

For your convenience, Great Smiles of Elizabeth will send an email and/ or text message to confirm your reserved appointment. If you need to change your scheduled appointment for any reason, please call our office 24 hours prior to your reserved time (48 hours for Saturday appointments). This will avoid any broken appointment charges. There is a broken appointment charge of $50.00 for each 30 minutes reserved.

□ Email Only

□ Text Message Only *

□ Email & Text Message *

□ None. I do not wish to receive any reminders.

Email Address: ______________________________

Cellular Phone: ______________________________

*Please Note: Standard text message rates apply. Contact your phone service provider for details.

Person Responsible for Account

Name of Patient (please print)

Date

Relationship to Patient

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