Dental History printable pdf download

D. D. S., F. A. G. D.

R I A N

U R T R Y ,

Fellow of the Academy of General Dentistry

Child’s Information

Male

Female

Today’s Date: _____________

Patient Name: _______________________________________________________ Nickname: __________________

Last

First

Social Security#:_________________________ Birth Date: ___________________Age: _________________

Address:

_______________________________________________________________________________

Street

Apartment #

_______________________________________________________________________________

City

State

Zip Code

Parent’s/Guardian Information

Parent Name: _________________________________________________________

Last

First

Male

Female

Married

Divorced

Separated

Widowed

Partnered

Single

If Divorced, who is the Legal and Financial Person responsible for your child: _________________________________

Social Security#:______________________________

Birth Date:______________________________________

Phone (Cell:

______________________________

Email Address: __________________________________

Phone (Home): ______________________________

Phone (Work): ___________________________________

Address:

_______________________________________________________________________________

(if different)

Street

Apartment #

_______________________________________________________________________________

City

State

Zip Code

Employer:

Occupation: _____________________________

Referral Information

Whom may we thank for referring you to our practice / How did you hear about us?

Name of person or office referring you to our practice:

________________________________________________

Internet (please circle): Google / Yahoo / Bing / Other. What was search term? ___________________________

New Homeowner Brochure w/magnet

Mountain Island Monitor

School Folder ( MICS , MIE )

Saw our sign driving by

Postcard in mail

Local Sports (Baseball / Soccer)

Little Ones Magazine

Other: ____________________________________________________

Consent for Services / Responsible Party Information

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice

depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the

part of each patient must be determined before treatment.

I understand I am responsible for any amount not paid by my insurance carrier.

I understand that the fee estimate listed for this dental care is valid for a period of six months from the date of the

patient examination.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to

this form and my account.

I consent and permit Dr. McMurtry to diagnose any and all dental conditions I may have.

By my scheduling subsequent treatment appointments, I consent and give permission to Dr. McMurtry and his staff to

treat the dental conditions previously diagnosed.

I have read the above conditions of treatment and payment and agree to their content.

____________________________________________________ Date: _____________ Relationship to Patient:

Signature of patient, parent or guardian

Dental History

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