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Brandon Martin_ DDS Martin Family _ Cosmetic Dentistry 1232

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									                                              Brandon Martin, DDS
                                       Martin Family & Cosmetic Dentistry
                                           1232 Camellia Blvd. Suite A
                                              Lafayette, LA 70508
                                              337-988-4060 phone
                                                337-988-4062 fax
                                         brandonmartindds@gmail.com
                                               www.smilingbig.com


At Martin Family & Cosmetic Dentistry, our team is committed to the highest quality of dental care and a
comfortable patient visit. We are a “boutique style” dental practice catering to patients of all ages. We
provide many services including dental cleanings and exams, digital x-rays, tooth-colored fillings, crowns and
bridges, partials and dentures, athletic mouth guards, and teeth whitening. We file most insurance and offer
“Care Credit” for easy financing of your dental procedures.

Enclosed is a Patient Information and Medical History form. Please complete this form and bring it with you
to your first exam. If you have dental insurance, complete the Insurance Information portion and bring your
dental card with you; without proof of insurance you will be responsible for the initial visit. We will
appreciate payment for the initial examination on your first visit if you do not have dental insurance. If you
have insurance, we will process an insurance claim as a service to you, and you will be responsible for any
balance your insurance does not cover.

Dental heath is not a one-time affair. Preventative dentistry is one of the most important services we have to
offer you and your family. Once treatment is completed, preventative examinations on a regularly scheduled
basis will give you and your family the maximum benefit for long term dental health.

You are more than welcome to fax this completed packet back to 337-988-4062 prior to your appointment,
along with copies of your dental insurance card.

We look forward to treating you and your family!

Dr. Brandon Martin, Michelle, Casey & Katina




                                             Our Mission Statement

                        We are a team of Empathetic & Compassionate dental professionals
                               striving to provide the highest quality of dental care
                              by catering to the individualized needs of our patients
                                       in a relaxing, stress-free environment
                                                   Patient Information Sheet

Patient’s Name: ___________________________________ Preferred Name: __________________
Address: ___________________________________________________________________________
___________________________________________________________________________
City: ____________________ State: _____Zip: ____________ DL# _________________
Home Phone: ___________________ Work Phone: _________________Cell : ________________
*I would like to be contacted by:                Home Phone                    Work Phone     Cell Phone
Birthdate: ___________________ _______ Age: ____ SOCIAL SECURITY # ______________________
Male / Female                     Marital Status:           Married Single Separated Divorced Widowed          Other
If patient is a minor (under 18) please give Parent or Guardian name: __________________________________
Patient’s Occupation: ______________________________________________________

Whom may we thank for referring you to our office:? _____________________________________________

Responsible Party Information (If other than self)

Name: _____________________________________________Date of Birth: _________________
Relationship to Patient: ____________________________________
Address: _____________________________________________________________________________
City: _____________________________ State: _________________ Zip ___________________
Employer: ____________________________ Occupation: _______________________________
Home Phone: ____________________________ Work or Cell Phone: _______________________


Dental Insurance Information (please provide a copy of the dental card)
Insured’s Name: ___________________________________________Insured SS# _____________
Insured’s Date of Birth: _____________________Insured’s Employer: ___________________________
Member ID or Policy # _________________________ Insurance Group # ____________________
Dental Insurance Company Name ___________________________Phone # _________________
*We do not accept secondary insurance. The patient is responsible at the time of service for any co-payment or
deductible



In case of emergency, who should be notified?

Name: __________________________________ Phone: ____________________ Relationship _____________




To the best of my knowledge all the proceeding answers are true and correct. I will inform your office of any changes
at the next appointment. Date: ____________________________

Signature of patient or guardian (if patient is a minor child): ____________________________________________
Print Name: ___________________________________________________
DENTAL HISTORY

Correct answers to the following questions will allow Dr. Martin to treat you on a more individual basis, providing care
appropriate for your particular needs. Your answers are for our records only and will be considered confidential.

Are you having any discomfort at this time?                                        Yes        No
Does Dental Treatment Make you Nervous?                        No         Slightly Moderately Extremely
What do you fear most about dental treatment?                  Pain                Time       Cost
Date of last Dental Visit? ____________________ Date of Last X-rays: _________________
Name of Previous Dentist __________________________________________________
May we contact your previous dentist for copies of records?                        Yes        No
Have you ever been treated for Periodontal Disease (gum disease)?                  Yes        No       Not Sure
How many times do you brush daily? ________________
If you are currently in orthodontic treatment/who is your Orthodontist? ______________________________

Do you have or have you had any of the following:

Use of any tobacco products? ……………………………………………………………………                                                          Yes        No
Bleeding and /or sore gums? ……………………………………………………………………                                                           Yes        No
Unpleasant taste, bad breath? ……………………………………………………………………                                                         Yes        No
Burning tongue/lip?                 …………………………………………………………………                                                    Yes        No
Frequent blisters on lips/mouth? …………………………………………………………                                                          Yes        No
Swelling/lumps in the mouth?…………………………………………………………………                                                            Yes        No
Ortho Treatment (braces)?.....................................................................................   Yes        No
Biting of cheeks or lips? ………………………………………………………………………………                                                         Yes        No
Clicking or popping of jaw? ………………………………………………………………………………                                                       Yes        No
Difficulty opening or closing jaw? ……………………………………………………………………                                                    Yes        No
Loose Teeth? ………………………………………………………………………………………………                                                                Yes        No
Sensitive to hot/cold or sweets? ……………………………………………………………………                                                      Yes        No
Clenching/Grinding? …………………………………………………………………………………                                                              Yes        No
Poor fitting dental work (partials, dentures, crowns)? ……………………………                                               Yes        No

Do you use the following:

Dental Floss?                                                                                      Yes                 No

Mechanical (Electric) Tooth Brush?                                                                 Yes                 No

Fluoride Rinse?                                                                                    Yes                 No


If you could wave a magic wand and change anything about your smile, what would you want to change?




On a scale of 1-10 (10 being the highest) what would you rate your overall smile? __________________________
MEDICAL HISTORY

*Although dental personnel primarily treat the area around your mouth, your mouth is part of your entire
body. Health problems that you may have or medication that you may be taking could have an important
interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Do you have or have you ever had the following:

Anemia        ………………………………………………………………………………………………………Yes                                    No
Asthma        ………………………………………………………………………………………………………Yes                                    No
Diabetes      ………………………………………………………………………………………………………Yes                                    No

Allergies
        To Penicillin ……………………………………………………………………………………… Yes               No
        To Codeine ……………………………………………………………………………………… Yes                  No
        To Anesthetic ……………………………………………………………………………………… Yes               No
        To Iodine      ……………………………………………………………………………………… Yes              No
        To Aspirin     ……………………………………………………………………………………… Yes              No
        To Ibuprofen …………………………………………………………………………………….. Yes               No
        To Sulfa Drugs ……………………………………………………………………………………… Yes              No
        To Latex       ………………………………………………………………………………………. Yes             No
        Other: (please list):                ___________________ _________________
                                             ___________________ _________________

Abnormal Heart Condition ………………………………………………………..                              Yes           No
Valve Replacement         ………………………………………………………..                             Yes           No
Mitral Valve Prolapse     ………………………………………………………..                             Yes           No
Hip/Joint Replacement     ……………………………………………………….                              Yes           No
Abnormal Bleeding         ……………………………………………………….                              Yes           No
Rheumatic Fever           ………………………………………………………..                             Yes           No
Hepatitis                 …………………………………………………………                              Yes           No
Aids/HIV                  …………………………………………………………                              Yes           No
High Blood Pressure       ………………………………………………………..                             Yes           No
Low Blood Pressure        ………………………………………………………..                             Yes           No
Cancer/Chemotherapy/Radiation………………………………………………..                             Yes           No
Tuberculosis          ……………………………………………………………………………                           Yes           No

Are you under the care of a physician now? Yes No
Are you taking any medications including over the counter every day?       Yes         No
Is Yes, what? _________________________________________________________________
Do you take aspirin daily?                                Yes        No
Do you take Vitamins daily?                               Yes        No _______________________
Do you take herbs or supplements?                         Yes        No _______________________
Do you think you may be pregnant?                         Yes        No
Do you take oral contraceptives daily?                    Yes        No

Date of last Medical Examination? _______________________ Name of Doctor: _______________________
                                            Martin Family & Cosmetic Dentistry
                                                1232 Camellia Blvd. Suite A
                                                   Lafayette, LA 70508
                                                   337-988-4060 phone
                                                    337-988-4062 fax


                                                 Our Office Financial Policy

          In our continued commitment to provide the highest quality of dental healthcare available to all of our patients
and to have those services comfortably affordable, we provide an office financial policy that creates maximum
flexibility for each of our patient’s individual needs. As always, we are here if you may have any questions.

INSURANCE
        We will gladly process your insurance claims as a service to you; estimate your deductible and the portion not
covered by insurance. The estimated amount not covered by insurance (insurance co-payment) is due at the time of
your treatment and may be paid by any of the options listed below. Our estimates are subject to final approval by
your insurance company, therefore the amount due to our office is subject to change. All balances on accounts are to
be paid within 30 days of the insurance claim and remain the responsibility of the patient. We no longer file claims for
secondary insurance companies. We will process your primary insurance claim and forward the necessary information
to you to file with your secondary. Payment will be due in our office after the primary Insurance has paid its portion.

PAYMENT OPTIONS

For crown/bridge and denture appointments, we accept one half down and one half due at completion

Mastercard/Visa/Discover/Debit Cards – We accept credit cards as payment for treatment. We do not accept American
Express

Carecredit – offers a separate line of credit to cover your entire family’s health care needs, it is a Dental Credit Card that
allows you to stretch your payments
     A line of credit can be established and approval takes less than 10 minutes
     There is no annual fee and no initial down payment required
     You can apply here in the office or online by going to carecredit.com
     These financial options will meet the needs of most every family in our practice. We have listened to your
        concerns and have made great effort to respond to those concerns. Thank you for your continued support.

I have read and agree to the office financial policy for Brandon Martin, DDS

Signature of Patient or Parent (if patient is minor child) __________________________________________
Date _________________

Print Name: _______________________________________________
                                                 BRANDON MARTIN, DDS
                                                1232 Camellia Blvd. Suite A
                                                   Lafayette, LA 70508
                                                   337-988-4060 Phone
                                                    337-988-4062 Fax

                                          CONSENT TO PERFORM DENTISTRY


    1.    I hereby authorize and direct Dr. Brandon Martin, DDS and/or dental auxiliaries of his choice to perform the
         following dental treatment or oral surgery procedure (s), including the use of any necessary or advisable local
         anesthesia, radiographs (x-rays) or diagnostic aids.
              a. Preventive hygiene treatment (prophylaxis) and the application of topical fluoride.
              b. Application of “sealants” to the grooves of the teeth.
              c. Treatment of diseased or injured teeth with dental restorations (fillings/crowns)
              d. Replacement of missing teeth with dental prosthetics (bridges, dentures, partials)
              e. Removal (extraction) of one or more teeth
              f. Treatment of diseased or injured oral tissue (hard or soft).
              g. Use of sedative drugs to control apprehension and/or disruptive behavior.
              h. Treatment of misplaced (crooked) teeth and/or oral development or growth abnormalities
              i. Use of general anesthesia to accomplish any necessary treatment.
    2. I understand that there are risks involved in this treatment and hereby acknowledge that these risks will be
         explained to me, that I will have an opportunity to ask questions regarding the treatment and the risks, and that
         I fully understand the same.
    3. I will be advised that the success of the dental treatment provided will require that the patient and/or parents
         follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment
         requires that all post-operative and post-care instructions be followed and that regular office visits as scheduled
         by my dentist and his auxiliaries must be maintained.
    4. I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different
         procedures from those diagnosed. I therefore authorize and request the performance of any additional
         procedures that are deemed necessary are desirable to oral health and well being, in the professional judgment
         of the dentist.
    5. There are possible risks and complications associate with the administration of local anesthesia, sedation and
         drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and
         numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the
         injection site), fainting, lip or cheek biting resulting in ulceration and infection of mucosa. I also understand
         that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular
         collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or
         death. I understand and have been informed of the above risks and complications.
    6. I agree to the use of local anesthesia and the use of nitrous/oxygen analgesia depending on the judgment of the
         dentist. Nitrous oxide may occasionally produce nausea and vomiting. I am also aware that the nose piece
         leaves an indention or ring around the nose, which disappears shortly after the procedure. I understand and
         have been informed of above risks and complications. – NOT USED IN THIS OFFICE AT THIS TIME
    7. I also authorize the dentist to use photographs, radiographs, other diagnostic materials and treatment records
         for purpose of teaching, research and scientific publications.
    8. I hereby state that I have read and understand this consent, and that all questions about the procedures will be
         answered in a satisfactory manner, and I understand that I have the right to be provided answers to questions
         which may arise during and after the course of my treatment.
    9. I further understand that this consent will remain in effect until such time that I choose to terminate it.
Date: ______________________ Patient’s Name (print) : _________________________________________
Signature of Patient (parent or guardian if patient is under 18) __________________________________________
Signature of Dr. Brandon Martin or Auxiliary: __________________________________
                                      Brandon M. Martin, DDS
                                     1232 Camellia Blvd. Suite A
                                        Lafayette, LA 70508
                                (Located between Settlers Trace Blvd.
                                  & Silverstone Rd in River Ranch)
                                             337-988-4060
                               Visit our Website: www.smilingbig.com
                              Accepting New Patients and Families




           “Committed to Quality Dentistry and a Comfortable Patient Experience”
        *Routine Dental Cleaning & Exams                             *Digital X-rays
        *Crowns & Bridges                                            *Cosmetic Bonding & Bonded fillings
        *Teeth Whitening                                             *Porcelain Veneers
        *Dental Implant Restoration                                  *Extractions
        *Sealants                                                    *Athletic Mouth Guards
        *Partials & Dentures                                         *Oral Sedation
        *Most Insurances Accepted & Filed                            *Interest Free Financing (with approved credit)
        *Family & Kid Friendly                                       *Boutique Style Atmosphere
        *Emergencies Seen Promptly                                   *Friendly, Knowledgeable Dental Team




          Driving Directions from Kaliste Saloom: Turn onto Camellia Blvd (stay in the left lane). Go through the first
intersection (Settler’s Trace Blvd.) go down about ½ block and make a left u-turn back onto Camellia Blvd. Our building
is located on the right (2-story white stucco building with brown shutters). Downstairs in the lobby, office A.

         Driving Directions from Johnston: Take Camellia Blvd to the intersection of Camellia and Silverstone Rd. We are
just past Silverstone on the right just before the Settler’s Trace intersection.

								
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