Plazadentalcare.com

Name:________________________________Preferred Name:_______________ Date of Birth_______________ Address:____________________________________________________________________________________ (If P.O. Box, please include street address) Telephone: Home:____________________ Business:____________________ Cell:_______________________ Employer:__________________________________SS #__________________Email______________________ Name of Spouse:____________________________ Name of Children:__________________________________ Referred by:____________________________, we would like to thank them. ❑ Family ❑ Co-Worker ❑ Neighbor ❑ Insurance ❑ Phone Book ❑ Newspaper ❑ Welcome Wagon ❑ Other________________ Person Responsible for Account (if other than patient)Name:_______________________________ Relationship:________________ S.S. #______________________ Address:____________________________________________________________________________________ Telephone: Home:____________________ Business:____________________ Cell:_______________________ I will be responsible for payment of the services furnished and agree to pay for such treatment regardless of insur- ance or any other third party involvement. I also agree, if the need arises for my account to be referred to collection, to pay all agency fees, court costs, attorney's and legal fees.
Signature __________________________________________________________ Date____________________ Dental Insurance InformationPrimary Insurance Co.:________________________________________________________________________ Employee:____________________________ Relationship:_______________ S.S. #_______________________ Employer:_______________________________________________ Policy Number_______________________ Employee's Date of Birth:___________________________ Secondary Insurance Co.:______________________________________________________________________ Employee:____________________________ Relationship:_______________ S.S. #_______________________ Employer:______________________________________________ Policy Number________________________ Employee's Date of Birth:___________________________ Please describe any specific dental problem or discomfort you are having at this time: _____________________________ _________________________________________________ How long has it been present? _____________________ If you have had any of the following dental care, please list the dentists and approximate dates: Periodontal (gum) treatment or surgery: _____________________________________________________________ "Braces" or any type of orthodontic treatment: _________________________________________________________ Dental Implants: ________________________________________________________________________________ Any other type of oral surgery: _____________________________________________________________________ Do you have / have you had / have you noticed any of the following signs or symptoms in your head, neck or mouth? (Please check Yes or No or each question) Yes No A clicking, snapping or difficulty when chewing An unpleasant taste or persistent bad breath Difficulty speaking or changes in your voice Difficulty moving your tongue or "tongue tied" Red, swollen, tender, bleeding or sore gums Changes in the way your teeth fit together Gums that have pulled away from the teeth A color change of the tissues in your mouth Sores, ulcers, or rough spots in your mouth How do you rate your overall dental health? How many times a day do you brush your teeth? _____ How many times a week do you floss your teeth?_____ Do you use any of the following? (Please check Yes or No for each question) Mechanical (electric) toothbrush If Yes, what type or brand? ____________________________________________ Flossing aids (floss holders, threaders, etc.) Fluoride treatments or supplements at home. If Yes, which ones: ___________________________________________ Mouthwashes or oral rinses. If Yes, what brand? ___________________________________________ Do you have any missing teeth that have not been replaced? Why have you not had them replaced? _______________________________________________________________ Do you wear any removable dental appliances? If Yes, what type and for how long? __________________________________________________________________ Have you ever had your teeth whitened or bleached? Would you like to have your teeth whitened or bleached? How do you feel about the appearance of your smile and what would you change if you could?_______________________________________________________________________________________________Are you frustrated because you always need something treated or repaired when you visit a dentist? Do you feel you will eventually wear artificial dentures? Have you ever had any complications from an extraction or dental treatment? If Yes, please explain ______________________________________________________________________________Have you ever had any other dental conditions, major trauma or injury to your head, neck or mouth? If Yes, please explain ______________________________________________________________________________If you are a new patient to this practice: Date of last dental visit __________________ Dentist's Name_________________________ City & State_________________________ Patient's Name:________________________________________________________________________ Date of Birth: ___________________ If you are completing this form for another person: Your name:_________________________________________ Phone:____________________ Relationship: ____________________________ Emergency Contact: (If not listed below) Name:______________________________________________Phone:____________________Relationship: ____________________________ Primary Physician:______________________________________Phone:_____________________City & State: ____________________________ Date of last physical examination:__________________________ Date of last blood test/work up: _____________________________________ Other Physicians & Specialists: Name:____________________________ Specialty:_____________________ Phone:____________________ City & State: ________________ Name:____________________________ Specialty:_____________________ Phone:____________________ City & State: ________________ 1. Within the last 3 years, have you been hospitalized or had surgery? If Yes, please give reasons and dates:_____________________________________________________________________ 2. Have you ever been instructed to take ANY medication or take ANY special precautions before any dental appointments? If Yes, please explain: __________________________________________________________________________________ 3. Are you taking ANY drugs, medications or treatments at this time? (If you brought a complete written list with you, give that to the receptionist instead.) Prescribed:___________________________________________________________________________________________ ____________________________________________________________________________________________________ Over-the-counter (OTC) medications (such as aspirin, Advil, allergy medications, sleeping aids, etc.): ____________________________________________________________________________________________________ Are you having or ever had radiation or chemotherapy treatments? If Yes, for how long?_________________ Name of facility performing the treatment:________________________________ 4. Are you taking or have you ever taken / been treated for osteoporosis with a Bisphosphonate (Fosamax, Boniva, Actonel, How long have you been taking this medication? ________________________ 5. Are you allergic to or have you ever experienced an unusual reaction to: ____ Latex 6. Are you allergic to or have you ever had any reaction to any of the following drugs? ____ Penicillin (or related drugs) ____ Aspirin / Ibuprofen (Advil, Motrin, Nuprin) 7. Have you ever had an allergic reaction or unusual response to ANY other medications, drugs, pills, or treatments? If Yes, please list: ______________________________________________________________________________________ 8. Do you have or have you ever had any of the following? (Please check Yes or No for each question) Tuberculosis, emphysema or lung disorder If Yes, type & date_______________________ If Yes, date ____________________________ Rheumatic heart disease / rheumatic fever Heart valve(s) damage / Mitral valve prolapse Ulcers, acid reflux, or stomach problems (Lupus, HIV, AIDS, radiation immune problem, etc.) Excessive bleeding from any cut or incident If Yes, what is your due date?______________ Any artificial joint, joint surgery or prosthesis If Yes, what joint or area:___________________ When was operation done?_________________ Hepatitis, jaundice, or other liver problems Are you taking hormone replacement therapy? 9. Do you have any other conditions, diseases or medical problems, or is there ANY other information that you would like us to know about, or that we should be made aware of? ❑ Yes ❑ No If Yes, please explain: ________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ CONSENT: To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the charges without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient's health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice.
I understand there are no guarantees or warranties in health or dental care.
Signature___________________________________________________ Date______________________ (Parent or guardian, if patient is a minor)

Source: http://plazadentalcare.com/wp-content/uploads/2013/04/Adult-Confidental-Info.pdf