SES-Adult-Patient

11390 E Via Linda Ste 104 Scottsdale, AZ 85259 | P: 480.867.1727 | F: 480.550.6521

smileesthetics.com
Patient Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
FemaleMaleGender Neutral
SS #
MarriedSingleWidowedSeparated
Address

Home Address

Street Address Line 2

CityState / Province

ZIP
Home Phone #
Cell Phone #
Email Address
example@example.com
Employer/Business Name
Employer Phone #
Occupation
YesNo
Phone CallTextEmail
Friend/FamilyGoogleInstagramFacebookInsuranceOther
Who may we thank for referring you to the office?
Person to contact in case of emergency
Person to contact in case of emergency contact number
Person responsible for account
SelfSpouseParentGuardian
For Dental Insurance Purpose
Subscriber Name
Date of Birth

MonthDayYear
Date
Relationship
Subscriber SS #
Subscriber Employer/Business Name
Dental Insurance
Claim Address
Group #
ID #
Insurance Phone #
Dental & Medical History
Previous dentist
Date of last visit

MonthDayYear
Date
Date of last x rays

MonthDayYear
Date
3 months4 months6 monthsNot routinely
InvisalignWhiteningVeneers
FairExcellentGoodPoor
How often do you brush?
How often do you floss?
YesNo
What is your immediate dental concern?
YesNo
Please describe
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Physician's Name
Phone #
Date of last visit

MonthDayYear
Date
ExcellentGoodFairPoor
Please type (Y) for “yes” or (N) for “no” for any of the following which may apply to you now or in the past:
Heart attack or Heart Trouble
Chest pain with exercise (angina)
Heart Valve disorder
Artificial Joint Replacement
When

MonthDayYear
Date
Excessive bleeding
Stroke
When

MonthDayYear
Date
Asthma
Ulcers, Gastric Reflux or Heartburn
Kidney problems
Headaches or Migraines
Tumors, Cancer, radiation treatment
Hepatitis, type
Psychiatric Disorders
Drug or Alcohol dependency
Congenital Heart Disease
High Blood Pressure
Pacemaker
Anemia or blood disorder
Diabetes, Recent A1C?
Thyroid disease
HPV
Stomach problems
Fainting
Pacemaker
Epilepsy or Seizures
Tuberculosis, lung problems
AIDS or HIV infection
Tobacco use, how much?
Sleep Apnea
YesNo
List any other medical issues you have
List any serious illness, surgery or hospitalization
List any medications, vitamins or herbs you are taking
List any allergies you have
Authorization and Consent
I understand the above information is necessary to provide dental care in a safe and efficient manner. I certify that the information provided above is accurate to the best of my knowledge. Should further information be needed, the Smile Esthetics Scottsdale staff has my permission to ask the respective health care provider or agency, who may release such information. I will notify the doctor or hygienist of any changes in my health care or medications.
I understand.
Consent to Treatment
I hereby authorize doctors or designated staff to take x-rays, study models and other diagnostic aids deemed appropriate to make a thorough diagnosis. Upon such diagnosis, I authorize the dental providers to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication.
I hereby authorize.
Release of Information & Payments
I authorize the release of any information relating to any claim to third party payers. I hereby authorize and request my insurance company to pay directly to the dentist or dental office insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I am aware that a missed appointment fee is $50.00. I agree to be responsible for payment of all services rendered on my behalf or my dependents’ behalf. I am aware that Smile Esthetics Scottsdale makes every effort to conform to HIPAA Privacy Regulations but that my health care information may be released in the course of coordination of treatment, obtaining payment and health care operations.
I authorize.
Photography Release
I authorize the dental office to take photographs of me or my dependents for identification and to help us better understand our current dental condition and treatment options. I agree that photographs may be shown to other patients, potential patients or doctors for educational purposes while our names and identifying information will be kept confidential.
I authorize.
Please Print Patient Name
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

For Dental Insurance Purpose

Dental & Medical History

Please type (Y​) for “​yes​” or (​N​) for “​n​o” for any of the following which may apply to you now or in the past:

Authorization and Consent

Consent to Treatment

Release of Information & Payments

Photography Release

Please type (Y) for “yes” or (N) for “no” for any of the following which may apply to you now or in the past: