Patient Information (Page 2 of 2) in pdf

MEDICAL HISTORY

Physician’s Name______________________________________________________________ Phone # ________________________

Are you under a physician’s care now?

Y N If yes, please explain: ___________________________________

Have you ever been hospitalized or had a major operation? Y N If yes, please explain: ___________________________________

Are you taking any medications, pills or drugs?

Y N If yes, please list: ______________________________________

Have you ever had a joint replacement?

Y N

______________________________________

Have you taken Phen-Fen or Redux?

Y N

______________________________________

Do you use tobacco?

Y N

______________________________________

WOMEN: Are you: Pregnant/trying to get pregnant? Y N

Nursing? Y N

Taking birth control pills? Y N

Are you allergic to any of the following?

Latex

Local Anesthetics

Penicillin

Erythromycin

Tetracycline

Aspirin

Codeine

Acrylic

Metals

Other If yes, please list _________________________________________________________________________

Do you have, or have you had, any of the following?

Y N AIDS/ HIV Positive

Y N Cortisone Medicine

Y N Hemophilia

Y N Radiation Treatments

Y N Anaphylaxis

Y N Diabetes

Y N Hepatitis A

Y N Recent Weight Loss

Y N Anemia

Y N Drug/Alcohol Abuse

Y N Hepatitis B or C

Y N Rheumatic/Scarlet Fever

Y N Arthritis/Gout

Y N Emphysema

Y N Herpes

Y N Rheumatism

Y N Artificial Heart Valve

Y N Epilepsy or Seizures

Y N High Blood Pressure

Y N Sickle Cell Disease

Y N Artificial Joint

Y N Excessive Bleeding

Y N Hives or Rash

Y N Sinus Trouble

Y N Asthma

Y N Excessive Thirst

Y N Hypoglycemia

Y N Stomach/Intestinal Disease

Y N Blood Disease

Y N Fainting Spells/Dizziness

Y N Irregular Heartbeat

Y N Stroke

Y N Breathing Problems

Y N Frequent Cough

Y N Kidney Problems

Y N Swelling of Limbs

Y N Bruise Easily

Y N Frequent Headaches

Y N Leukemia

Y N Thyroid Disease

Y N Cancer

Y N Glaucoma

Y N Liver Disease

Y N Tonsillitis

Y N Chemotherapy

Y N Heart Attack/Failure

Y N Low Blood Pressure

Y N Tuberculosis

Y N Chest Pains/Angina

Y N Heart Murmur

Y N Lung Disease

Y N Tumors or Growths

Y N Cold Sores/Fever Blisters

Y N Heart Pace Maker

Y N Pain Jaw Joints

Y N Ulcers

Y N Congenital Heart Disorder

Y N Heart Trouble/Disease

Y N Psychiatric Care

Y N Yellow Jaundice

Have you ever had any serious illness not listed above? Y N If yes, please explain _________________________________________

____________________________________________________________________________________________________________

FINANCIAL POLICY

Payment is due in full at time of treatment – unless prior arrangements have been made.

As a courtesy to you, our office will bill your dental insurance company. It is your responsibility to know your insurance benefits,

maximums, limitations and frequencies. Please be prepared to pay your portion of payment or co-pay at the time of service.

If your insurance denies claims, it is your responsibility to solve the problem with your insurance company. Our office will be happy

to resubmit claims up to three times.

The responsible party agrees:

1. To make payment in full at time of treatment or service.

2. To be responsible for additional cost and/or responsible attorney’s fees if any delinquent balance is placed with an agency

or attorney for collection or suit.

3. To pay a 40% collection fee, which will be added to the outstanding balance.

4. An additional finance charge of 1.5% per month (18% per year) which will be applied to any account that has not been paid

in full after 60 days.

I understand that I am financially responsible for all charges whether or not paid by insurance. Also, I am aware that if I fail to show

to my scheduled appointment or give less than a 24 business hour notice I will be charged a $25.00 no show fee for every hour I was

scheduled.

Signature __________________________________________________________________ Date ____________________________

Patient Information Page 2

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