DENTAL INSURANCE Primary Dental Insurance Secondary Dental

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DENTAL INSURANCE Primary Dental Insurance Secondary Dental Powered By Docstoc
					PATIENT INFORMATION                                        DENTAL INSURANCE
Name: _______________________________                                        Primary Dental Insurance
         Male          Female
                                                           Insured/Policy Holder_________________________________________
Birth date: _______ / _______ / _________
                                                           Birth date: ____ / _____ / _______ SS#: ________-______-_________
SS# _________-_________-__________
                                                           Insured’s Employer: __________________________________________
Home Address:
                                                           Relationship to insured: ________________________________________
                                                           Ins. Co.:____________________________________________________
                                                           Ins. Address: ________________________________________________
Mailing address if different from home
                                                           Ins. Phone: _________________________________________________
address: _____________________________________
                                                           Group #: ___________________________________________________
                                                                          Secondary Dental Insurance
Email: ____________________________________
Mobile # :(________) ________________________              Insured/Policy Holder_________________________________________

Do you use text messaging?         Yes       No            Birth date: _____/______/_______ SS#: ________-______-_________
                                                           Insured’s Employer: __________________________________________
Home #: (_______) __________________________
                                                           Relationship to insured: ________________________________________
Work #: (______) ______________ Ext. _________
Employer: _________________________________                Ins. Co.:____________________________________________________

Occupation: _______________ How Long? ______               Ins. Address: ________________________________________________

May we contact you at work?          Yes     No            __________________________________________________________
                                                           Ins. Phone: _________________________________________________
Emergency Contact:
Name: ____________________________________                 Group #: ___________________________________________________

Phone: ____________ Relationship: ____________                  RESPONSIBLE PARTY (If different from patient)
                                                           Name: ______________________________________________
Who may we thank for referring you?                        Home address: ________________________________________
__________________________________________                 ____________________________________________________
Do you have any family members who come to                 Home #: (________) _________________________________________
Dental Dynamics? If so, who? __________________            Work #: (________) ________________ Ext. _____________________
                                                           Birth date: ______ / ________ / _______ SS# ________-________-_________


I authorize Doctor and his/her staff to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by
doctor to make a thorough diagnosis. I also authorize the Doctor to perform any and all forms of treatment, medication, and
therapy that may be indicated. I also understand that the use of anesthetic agent, medications, and some dental procedures embody
a certain risk. I understand that 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 financial arrangements have been made. I authorize my insurance
company to pay the Doctor all the insurance benefits for services rendered. I also authorize the release of all information necessary
to secure the payment of benefits.

Patient Signature (Parent/Guardian):_____________________________________ Date:
                                                              Thank you for selecting Dental Dynamics!
                                                       Please take a few minutes to fill out this form as completely as you can.
                                                        If you have any questions, please ask us – we will be glad to help you.

Name: __________________ Date: __________                         MEDICAL HISTORY
I prefer to be called: _____________________________
______________________________________________                    Do you have a personal physician             Yes         No
                                                                  Physician’s Name_____________________________________
Why have you come to the dentist today? ____
                                                                  Phone#_______________ Date of Last Visit? _______________
Are you currently in pain?               Yes         No           Your current physical health is:         Good           Fair        Poor
Have you ever had a difficult or bad previous dental
                                                                  Are you currently under the care of a physician?        Yes     No
experience? Yes            No          If so, please
                                                                  Please Explain: _______________________________________
                                                                  Are you taking any prescriptions/over the counter drugs?
_____________________________________                                Yes       No If so, please list:
Do you now have or have you ever experienced pain or
discomfort in your jaw joint (TMJ/TMD)?          Yes     No
                                                                  Are you taking any herbal or vitamin supplements, if so please
Do you get headaches and if so, how frequent?
                                                                  list: _________________________________________________
                                                                  Are you currently taking or have you ever been on osteoporosis
Do you clench or grind your teeth?         Yes         No
                                                                  drugs such as Fosamax?       Yes        No Please list
Your current dental health is:    Good       Fair      Poor
                                                                  For Women: Are you taking birth control pills?           Yes    No
Would you like to learn more about any of the following
                                                                  Are you pregnant?      Yes (week #______)                  No
procedures to enhance your smile? Check all that apply
                                                                  Are you nursing?          Yes       No
     Zoom Whitening              Veneers
                                                                  Have you ever had any of the following?
    Invisalign                   Lumineers                                                               Difficulty Breathing
                                                                           Heart Attack/Stroke
     Other_____________________________________                            Cancer/Chemotherapy           Epilepsy/Seizure/Fainting spells
                                                                           Heart Murmur                  Diabetes/Tuberculosis (TB)
Do your gums ever bleed?         Yes         No
                                                                           Rheumatic Fever               Drug/Alcohol Abuse
How often do you floss? ________________________________                   HIV + / AIDS                  Sleep Apnea
How many times a day do you brush? ___________________                    Heart Surgery/Pacemaker        Hemophilia/Abnormal Bleeding
                                                                          Mitral Valve Prolapse          Congenital Heart defect
                                                                          Kidney Problems                Anemia/Radiation Treatment
                                                                          Artificial Bones/Joints        Asthma/Arthritis
Previous Dentist: ____________________                                    Artificial Valves              Developmental Disability
Location/City/State: _________________
Last Visit Date: _____________________
                                                                          Sinus Problems                 Hospitalization for any reason
                                                                          High/Low Blood Pressure Hepatitis
                                                                          Blood Transfusion              Severe/Frequent Headaches
Please rank your concerns regarding dental
treatments 1-4 with 1 being most important
                                                                          Emphysema/Glaucoma             Other:_____________________
                                                                          Are you allergic to any of the ___________________
____ Cost of treatment
____ Fear of pain or discomfort                                   Y   N Penicillin Y N Tetracycline                  Y   N Percodan
____ Lack of concern/neglect                                      Y   N Aspirin     Y N Dental Anesthetics           Y   N Demerol
                                                                      N ErythromycinY N Codeine                      Y   N Valium
____ Missing work time
                                                                  Y   N Latex       Other_______________             Y   N Sulfa
What motivates you to come to the dentist?
Please rank 1-4 with 1 being most important
                                                                  Y N Tobacco Use? Frequency: _______________________________
____ Maintaining good overall health
____ Avoiding discomfort with teeth                               Med Hx reviewed by _____________________ Date ______________
____ Maintaining a beautiful smile
____ Maintaining a good ability to chew and                       Dr’s Comments: ____________________________________________
     function                                                     __________________________________________________________

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