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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