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Patient Info - Excel

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					                 Welcome!                                              Dr. Allan Finkleman*
                                                                        Dr. Alex Zimmer*
                                                                    *Services provided by dental corporation

                     PATIENT INFORMATION                 1               DENTAL INSURANCE                      3
                         GETTING TO KNOW YOU                                 PRIMARY CARRIER
NAME                                                         INSURANCE
                                                             COMPANY
I PREFER TO BE CALLED                                        EMPLOYEE

DR.       MR.     MRS.       MS.     MISS     OTHER:         GROUP #

ADDRESS                                                      EMPLOYEE #/ID #

CITY /PROVINCE                               POSTAL          DATE OF BIRTH
                                              CODE
PHONE (HOME)                                                 MAXIMUM                    DEDUCTIBLE

       (WORK)                                                % BASIC                    % MAJOR

       (CELL)
                                                                          SECONDARY CARRIER
EMAIL ADDRESS                                                INSURANCE
                                                             COMPANY
DATE OF BIRTH                                  AGE           EMPLOYEE

WHO MAY WE THANK                                             GROUP #
FOR REFERRING YOU?
                                                             EMPLOYEE #/ID #

                                                             DATE OF BIRTH
                     ACCOUNT INFORMATION                 2
                                                             MAXIMUM                    DEDUCTIBLE
          PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
NAME                                                         % BASIC                    % MAJOR

RELATIONSHIP TO PATIENT
                                                                          METHOD OF PAYMENT
ADDRESS                                                                     CASH             CHEQUE

CITY/PROVINCE                                 POSTAL                    CREDIT CARD         DEBIT CARD
                                               CODE
PHONE NUMBERS


                                   YOU                                                                         4
EMPLOYER                                                       We require 48 hours notice to reschedule
                                                              appointments; we charge a fee for broken
                                                              appointments without sufficient notification.
OCCUPATION
                                                                Payment is due on the day of treatment.
WORK ADDRESS                                                  Interest will be charged on overdue accounts
                                                              at 1.5% per month, or 18% per annum.
CITY/PROVINCE                                 POSTAL
                                               CODE             I, the undersigned, understand that it is
                                                              my responsibility to pay for dental treatment
                        YOUR SPOUSE/PARTNER                   for both myself and for my dependents. I
NAME                                                          assume all responsibility for fees associated
                                                              with my/our dental treatment.
EMPLOYER                                    OCCUPATION

WORK ADDRESS
                                                                                SIGNATURE:
CITY/PROVINCE                                 POSTAL
                                               CODE
PHONE (WORK)                                                 DATE
3




4
DR. ALLAN FINKLEMAN                                                                                                      DR. ALEX ZIMMER

                                              HEALTH QUESTIONNAIRE
PATIENT'S NAME                                                       MEDICAL
                                                                     DOCTOR'S NAME
DATE OF BIRTH                                        AGE              MEDICAL
                                                                      DOCTOR'S PHONE #
PHARMACY,                                                             DATE OF LAST                                  BLOOD
IF APPLICABLE                                                         MEDICAL VISIT                                PRESSURE

                           DO YOU HAVE, or HAVE YOU EVER HAD, any of THE FOLLOWING CONDITIONS?
     ACID REFLUX DISEASE                DIABETES                             HIGH CHOLESTEROL                   MALIGNANT HYPERTHERMIA

     AIDS/HIV INFECTION                 DRUG/ALCOHOL DEPENDENCY              HIGH/LOW BLOOD PRESSURE            MENTAL HEALTH PROBLEMS

     ALZHEIMER'S DISEASE                EPILEPSY/SEIZURES                    IMMUNE DISORDERS                   NECK/BACK PROBLEMS

     ANGINA/CHEST PAIN                  FAINTING                             INFECTIVE ENDOCARDITIS             NEUROLOGICAL DISORDERS

     ANOREXIA/BULIMIA                   GASTRO-INTESTINAL DISEASE            INJURY TO FACE/JAW                 ORGAN TRANSPLANT

     ARTHRITIS                          HEART ATTACK                         JOINT REPLACEMENT                  RADIATION/CHEMOTHERAPY

     ASTHMA                             HEART MURMUR                         KIDNEY DISEASE                     STROKE

     BLOOD DISORDERS                    HEART PACEMAKER                      LIVER DISEASE/JAUNDICE             THYROID PROBLEMS

     CANCER/TUMOURS                     HEART VALVE CONDITION                LOSS OF EYESIGHT                   TUBERCULOSIS

     COLD SORES/CANKERS                 HEART -- OTHER                       LOSS OF HEARING                    VENEREAL DISEASE

     CONGENITAL HEART DISEASE           HEPATITIS                            LUNG DISEASE                       NONE OF THE ABOVE***

     OTHER ILLNESSES (OR SURGERIES) -- PLEASE EXPLAIN:                       CONCERNS WITH DENTAL TREATMENT -- PLEASE EXPLAIN:




      Please list all MEDICATIONS taken (Including over-the-counter drugs, vitamins, and herbal supplements, etc.)
1                                                                    PURPOSE OF DRUG

2                                                                    PURPOSE OF DRUG

3                                                                    PURPOSE OF DRUG

4                                                                    PURPOSE OF DRUG

5                                                                    PURPOSE OF DRUG


      INR LEVEL                                               STAFF NOTES:                                                   PROPHYLACTIC
      REQUIRED                                                                                                                ANTIBIOTICS
      (2.0 - 3.0)                                                                                                              REQUIRED

                       Have you had any ADVERSE EFFECTS or ALLERGIC REACTIONS to any of the following?

         CODEINE                   PENICILLIN                LOCAL ANESTHETICS                    LATEX                       METAL

    OTHER ALLERGY -- PLEASE EXPLAIN:                                                                               NO KNOWN ALLERGIES

                          SMOKING STATUS                                                        GENERAL RELEASE

    NON-SMOKER                                                        To be best of my knowledge, the questions on this form have been
                                                                      accurately and completely answered. I will not hold my dentist or any
                                                                      members of his staff responsible for any errors or omissions that I may
    PAST SMOKER          FROM ___________       TO   ____________     have made in the completion of this form. I acknowledge that it is my
                                                                      responsibility to inform my dental office of any changes in my health
    SMOKER              SINCE ___________ .   #/DAY ____________      status and/or medications.

              WOMEN ONLY -- ARE YOU PREGNANT?                         SIGNATURE OF
                                                                      PATIENT (OR GUARDIAN)
                                                                      DATE                                        STAFF
    YES -- DUE DATE:                                            NO
                                                                                                                  INITIALS
DR. ALEX ZIMMER

				
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