Medical History Form

Medical History

Please complete the fields below.
Full Name *

First Name Last Name
What is your Gender? *

Male Female
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Home Number

Area Code Phone Number
Wireless Number *

Area Code Phone Number
Do you have or have you ever had any of the following? Please check all that apply. * This Condition May Require Antibiotic Pre-medication for Certain Dental Procedures *

Allergies/Hay Fever Anemia Angina Arthritis Artificial Joints* Artificial Heart Valve* Asthma Breathing Problems Cancer Chemical Dependency Chemotherapy Diabetes Epilepsy Excessive Thirst Fainting/Dizziness Fever Blister/Cold Sores Frequent Cough Glaucoma Heart Disorder (Congenital)* Heart Infection* Heart Murmur* Heart Pace Maker* Heart Surgery* Hepatitis High Blood Pressure HIV/AIDS Kidney Problems Liver Problems Mental Disorders Mitral Valve Prolapse Osteoporosis Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sickle Cell Disease Sinus Problems Stroke Surgical Shunt* Thyroid Problems Tuberculosis Ulcers Venereal Disease Yellow Jaundice NONE OF THE ABOVE Other
Do you have any health problems that were not listed above or that need further clarification? *

Yes No
If yes, please explain:
Are you now under the care of a physician? (More than Routine Care) *

Yes No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past 2 years? *

Yes No
If yes, please explain:
Are you taking any medications or herbals? *

Yes No
If yes, please list. If no, indicate none: *
Have you used tobacco? *

Yes No
If yes, please explain:
Are you allergic to any medications or substances? If yes, please check all applicable boxes below: *

Yes No Aspirin Penicillin Codeine Iodine Metal Latex Other
Have you been diagnosed with COVID-19 or come in direct/close contact with someone that was confirmed positive? *

Yes No
If yes, please explain. If no, indicate N/A: *
WOMEN - Please check if applicable:

Pregnant Trying to get pregnant Nursing Birth Control Menopause Other
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medications change, I will inform the dentist and staff at the next appointment without fail.
Signature of Patient, Parent, or Guardian *
APPOINTMENTS

We value your time so you can expect us to see you at the appointed and to keep your time spent in our office as short as possible. In return, when you make an appointment with us, please be on time as we have reserved our time just for you. Please make every effort not to change your scheduled appointment. If you must change an appointment, please provide us at least 24-hours advanced notification so that we may use our time to accommodate other patients. Broken and missed appointments create scheduling problems for other patients and our practice. If you are more than 10 minutes late for your appointment, you may be asked reschedule. We value your time, so we ask that you please value ours as well.
All missed/broken appointments without 24-hour notice will incur a $50 no-show/late cancellation fee. Please initial acknowledgment of fee: *
FINANCIAL POLICY

Unless another financial option is PRE-ARRANGED, payment is due the day of treatment, or on pre-op visits for sedation appointments. Should a patient have dental insurance with assignment to Dr. Cansler, the estimated patient portion will be the amount due. Insurance payments without assignment will be sent to the insured with payment due in full. Payment Options: For your convenience we accept cash, check, Visa, MasterCard, and Discover. We do not currently accept American Express, CareCredit, or LendingClub. For Patients with Dental Insurance: Dental insurance plans often pay less than the actual fee for service, therefore the patient or guarantor is the responsible party for all the dental services provided. Dental insurance in most cases is a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be estimated and explained to you during the treatment discussion appointment. MEDICARE: Dr. Cansler does not participate with ANY Medicare plans and is considered "Opted Out". Medicare does not pay for any covered items or services you get from an opted out doctor or other provider, except in the case of an emergency or urgent need. Payment will be due at the time of service. We are happy to provide an itemized receipt to you if you choose to attempt to seek reimbursment from Medicare directly. We will allow a maximum of 90-days for your insurance company to clear account balances. Any unpaid portions will be due in full by you after this period. Fees: Returned checks are subject to a $30 account fee or 5% of check amount over $600.
AUTHORIZATION AND CONSENT

General Consent to Treatment: I agree and consent to a dental examination by Dr. Cansler. I understand that additional diagnostic procedures and dental treatment may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed. Release of Information: I authorize Dr. Cansler to release an information regarding my dental/medical history, diagnosis or treatment to third party payors and/or other health professionals. Assignment of Insurance Benefits: I authorize and request my insurance company to pay my benefits directly to Dr. Cansler. Photography Release: I authorize Dr. Cansler to take photographs of me to help me better understand my current dental condition and possible treatment options. I understand and will comply with Appointment Policy. I understand and comply with the office Financial Policy. I understand and agree to the General Consent for Treatment.
Signature of Patient, Parent, or Guardian *
NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION

I hereby acknowledge that I have reviewed Cansler Dental’s Notice of Privacy Practices. I understand that I may ask any questions I might have regarding this notice.
Signature of Patient, Parent, or Guardian *
Please verify that you are human *
Should be Empty:

Medical History

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medications change, I will inform the dentist and staff at the next appointment without fail.

APPOINTMENTS

FINANCIAL POLICY

AUTHORIZATION AND CONSENT

NOTICE OF PRIVACY FOR PROTECTED HEALTH INFORMATION