Patient Information Responsible Party Dental Insurance Information by vyo46383

VIEWS: 28 PAGES: 3

									                              Thank you for selecting our dental office. We will strive to
                              provide you with the best possible care. To help us meet all
                              your dental goals, please complete this form.



Patient Information

Name __________________________ I prefer to be called ______________ Date of Birth _____________
Address __________________________City ____________ Province ___________Postal Code _____________
Marital Status ________________
Home Phone ______________Cell Phone ______________ Work Phone ______________ Ext _______
What is the best number to reach you at? Home      Cell    Work
Employer _______________________ Occupation _____________________

How did you hear about our dental office? _________________________________________________
Other family members seen by us ____________________________________

Would you like to receive your dental checkup reminder by email?       Yes     No
Email Address ________________________________________

Responsible Party

Name of the person responsible for this account _________________________
Relationship _____________________ Are they a patient in our office? Yes  No
Address __________________________City ____________ Province ___________Postal Code _____________
Home Phone ______________Cell Phone ______________ Work Phone ______________ Ext _______

Dental Insurance Information
Primary Insurance
Name of Insured ___________________________ Relationship ________Date of Birth of Insured _____________
Name of Insurance Company ________________________________
Insurance Policy/Certificate # _________________ Group # _____________

Secondary Insurance
Do you have any additional dental insurance? Yes       No
Name of Insured ___________________________ Relationship ________Date of Birth of Insured _____________
Name of Insurance Company ________________________________
Insurance Policy/Certificate # _________________ Group # _____________

Health History (Confidential)
Name of Medical Doctor _______________________ Phone Number ___________
Date of Last Visit to Medical Doctor ___________________

Have there been any problems in your general health within the past 5 years? (Serious illness, hospitalization,
surgery, etc.)  Yes    No If yes, please explain _________________________________________


                                                                                                       1
Are you taking any medications? (Please list all)
______________________________________________________________
______________________________________________________________
______________________________________________________________

Do you have a medical condition that requires you to take antibiotics before receiving dental treatment?
  Yes     No
Have you been diagnosed with the following conditions? (Check all that apply)
    Asthma                         Shortness of Breath/Chest Pain      High Blood Pressure
    Tuberculosis                   Hemophilia                          Low Blood Pressure
    Diabetes                       Hepatitis A, B or C (specify)       HIV and/or AIDS
    Kidney Trouble                 Back Problem/Surgery                Smoker
    Heart Condition                Cancer                              Allergy
 Specify:                        Specify:                           Specify:


Do you have any other medical conditions we should be aware of? Yes No
Please Specify: ________________________________________________________________

For Women:
Are you taking birth control pills?   Yes    No
Are you pregnant? Yes (week#          )      No


Dental Health History
Do you floss daily?     Yes     No Do you brush daily?        Yes    No Do your gums ever bleed?           Yes   No

Have you ever been told you have periodontal disease? Yes    No If yes, when? ________________________
Are your teeth sensitive to any of the following?   Heat  Cold   Sweet      Pressure
Do you experience discomfort in your jaws (TMJ/TMD)?     Yes   No

Previous Dentist: __________________________________________ Date of last visit: ____________________
Reason for leaving last dentist: _________________________________________

Are you happy with the way your smile looks? Yes    No
            If no, why not? ___________________________________________
Would you like whiter teeth? Yes      No

Authorization
I affirm that the information I have given on this form is correct to the best of my knowledge and it is my
responsibility to inform this office of any changes. I understand that I am responsible for the payment of the balance
of my account. I also authorize The Dental Office at Lyon & Glebe to release any information required to process
my claims. I UNDERSTAND THAT PAYMENT IS DUE AT THE TIME OF SERVICE.

__________________________                        ____________________
 Signature                                          Date



                                                                                                       2
  OUR APPOINTMENT CANCELLATION POLICY



At The Dental Office and Lyon & Glebe, appointments are made
in advance by reserving the appropriate time slots to accommodate
you and your treatment. Our staff spends time meticulously
preparing for each appointment by sterilizing, organizing and
arranging specify items needed prior to your arrival. This ensures
that we achieve the highest standard of care and treatment that we
pride ourselves on.

We therefore require at least 2 business days notice prior to
canceling or rescheduling appointments. Patients who cancel or
reschedule their appointments without proper notice will be
billed a $50.00 fee to offset the lost production and estimated
amount of time and effort the staff has already spent preparing
for the appointment.



We appreciate your help in this matter.

Patient Signature:

Date:




                                                                 3

								
To top