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WE LOOK FORWARD TO GETTING TO KNOW YOU AND CREATING YOUR DREAM SMILE NEW PATIENT MEDICAL FORM IN DALLAS, LAKEWOOD, WHITE ROCK, AND ALL OF NORTH & EAST DALLAS



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New Patient Information Form

We are pleased you have selected us to provide dental for you and your family.

Whom may we thank for referring you to our office?

Patient Information

Date Patients Name
       Last           First           Middle
 

Address
                        Street               Unit#             City           State                  Zip

Home Number Work Number     
Cell Phone        Social Security  
Email   

Birthdate
Month/Date/Year
Sex

Male   

Female

If patient is a minor, give parent's/guardian's name
Name of nearest relative not living with you Relationship
If patient is a full-time student, fill in school name
School Address School Ph. #
Emergency Contact Emergency Ph. #

Responsible Party Information

Responsible Party Name Relation to Patient
Responsible Party Employer Occupation No. Years Employed
Employer Address
Spouse's Name
Soc. Sec. # Birth Date Work Ph. #
Employer
Occupation No. Years Employed
Employer Address

Insurance Information

Insured's Name Insured's Soc. Sec or ID # Insured DOB
Insurance Company
Group #
Insurance Co. Address
Insurance Ph. #
Do you have dual coverage?

Yes -- If yes: Please complete the following secondary insurance information

No

Name of Union

Local #

Insured's Name
Insured's Soc. Sec or ID#
Insurance Company
Group # Local#
Insurance Co. Address
Union Ph. #
Insured's Employer
Employer Ph. #

Dental Information

Do your gums bleed when you brush?
Yes No
Are your teeth sensitive to heat or cold?
Yes No
Pressure?
Yes No
Sweets?
Yes No
Do you grind or clench your teeth?
Yes No
Do you have any fear of dental work?
Yes No
Date of last dental visit
What was done at the time?
Former Dentist Name City
How would you describe your current dental problem?
How do you feel about the appearance of your teeth?
1. Are you having pain or discomfort at this time?
Yes No
2. Have you been a patient in the hospital during the last two years?
Yes No
3. Are you now taking any medication or drugs?
Yes No
If yes, please list
4. A. Have you taken any medication or drugs during the past two years?
Yes No

    B. Have you ever taken appetite suppressants - fen-phen (fenluramine & Phentermine) or dexfenfluramine or fenflurameine?
Yes No

5. Have you been under the care of a medical doctor during the last two years or since taking any of the appetite suppressants named above?
Yes No
Physician's Name
Physician's Ph. #
Address
6. Are you sensitive or allergic to any medication or anesthetics?
Yes No
If yes, please list
7. Indicate which of the following you have had or have at the present.
Check "yes or no" to each item
Heart Failure?
YesNo
Artificial Joints (hip, knee, etc.)? Yes No Hepatitis?
Yes No

If yes, which strain (A,B,C,D)?

Heart Disease or Attack?
Yes No
Kidney Trouble?
Yes No
Venereal Disease?
Yes No
Angina Pectoris?
Yes No
Ulcers?
Yes No
A.I.D.S.?
Yes No
Congenital Heart Disease?
Yes No
Diabetes?
Yes No
H.I.V. Positive?
Yes No
Heart Murmur?
Yes No
Thyroid Problems?
Yes No
Cold Sores/Fever Blisters?
Yes No
High Blood Pressure?
Yes No
Glaucoma?
Yes No
Blood Transfusion?
Yes No
Arteriosclerosis?
Yes No
Cancer?
Yes No
Hemophilia?
Yes No
Mitral Valve Prolapse?
Yes No
Emphysema?
Yes No
Anemia?
Yes No
Artificial Heart Valve?
Yes No
Chronic Cough?
Yes No
Sickle Cell Disease?
Yes No
Heart Pacemaker?
Yes No
Tuberculosis?
Yes No
Bruise Easily?
Yes No
Heart Surgery?
Yes No
Asthma?
Yes No
Liver Disease?
Yes No
Rheumatic Fever?
Yes No
Hay Fever?
Yes No
Yellow Jaundice?
Yes No
Arthritis?
Yes No
Allergies or Hives?
Yes No
Epilepsy or Seizures?
Yes No
Rheumatism?
Yes No
Sinus Trouble?
Yes No
Fainting or Dizzy Spells?
Yes No
Cortisone Medicine?
Yes No
Radiation Therapy?
Yes No
Nervousness?
Yes No
Drug Addiction?
Yes No
Chemotherapy?
Yes No
Tumors?
Yes No
Stroke?
Yes No
Developmentally Disabled?
Yes No
Osteoporosis?
Yes No
Allergy to Latex?
Yes No
Allergy to Metal (jewelry, etc.)?
Yes No
 
8. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired? Yes No
9. Do your ankles swell during the day? Yes No
10. Do you use more than two pillows to sleep? Yes No
11. Have you lost or gained more than ten pounds in the past year? Yes No
12. Do you ever wake up from sleep and feel short of breath? Yes No
13. Are you on a special diet? Yes No
14. Do you have or have you had any disease, condition, or problem not listed? Yes No
     If yes, please list:

FOR WOMEN ONLY:

Are you pregnant? Yes  No
What Month?
Are you nursing? Yes No
Are you taking birth control pills? Yes No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I have answered all questions truthfully and to the best of my knowledge.

Patient Name Date

CONSENT:

  1. The undersigned hereby authorizes doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient's dental needs.
  2. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with (name of patient) . I understand that using anesthetic agents embodies a certain risk.  Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment.
  3. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made. In the events payments are not received by the agreed upon dates, I understand that a 1 - 1/2% finance charge (18 APR) may be added to my account, in addition to any collection charges.
  4. I understand that where appropriate, credit bureau reports may be obtained.
  5. I understand that it is my responsibility to advise your office of any changes in the information obtained on this form.
  6. I authorize the use of my social security number to file my dental claim.
Patient Date Witness
Parent or Responsible Party Relationship to Patient  

FOR OFFICE USE:

Reviewed by Dr. ____________________ Date: _____________________________