Confidential Patient Information
Name
*
Birthdate
*
-
Month
-
Day
Year
Social Security #
*
Drivers License #
*
Address:
*
Street
Street Address Line 2
City
State
Zip
Phone:
*
Home Phone
Work Phone
Cell Phone
Status
*
Single
Married
Widowed
Divorced
Separated
Patient or Parent’s Employer
*
Email:
*
How did you hear about us?
*
Emergency Contact
*
Phone
*
Dental Insurance Information
Name of Insured
Relationship to Patient
Birthdate of Insured
-
Month
-
Day
Year
Date
Social Security #
Name of Employer
Name of Insurance
Group #
Subscriber ID #
Insurance Address
Street
Street Address Line 2
City
State
Zip
Insurance Phone #
Deductible
Annual Max Benefit
Do you have additional insurance?
If so, please complete the following information.
Name of Insured
Relationship to Patient
Birthdate of Insured
-
Month
-
Day
Year
Date
Social Security #
Name of Insurance
Name of Employer
Group #
Subscriber ID #
Insurance Address
Street
City
State / Province
Postal / Zip Code
Insurance Phone #
Deductible
Annual Max Benefit
Signature of Patient/Responsible Party
*
Date
*
-
Month
-
Day
Year
Date
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Health Questionnaire
DENTAL
Please check any of the following which you have had or have at the present. You must mark each question, please.
Are you having any discomfort at this time?
*
YES
NO
Date of last dental visit
*
-
Month
-
Day
Year
Date
Does dental treatment make you nervous?
*
No
Slightly
Extremely
Have you ever had any serious trouble associated with previous dental treatment? If so, please explain.
Have you ever been treated for periodontal disease?
*
YES
NO
If so, when?
Do you use the following?
Brush
Dental Floss
Fluoride Rinse
Other
How often do you brush?
*
Brush is:
*
Soft
Medium
Hard
Do you like the appearance of your teeth? If not, what would you like to improve?
*
Do you currently take an antibiotic premedication for dental procedures? Reason:
*
Do you, or have you ever used tobacco products? For how long?
*
MOUTH
*
YES
NO
Bleeding, sore gums
Unpleasant taste/bad breath
Burning tongue/lips
Frequent blisters, lip/mouth
Swelling/lumps in mouth
Ortho treatment (braces)
Biting cheeks/lips
Clicking/popping jaw
Difficulty opening or closing jaw
TEETH
*
YES
NO
Loose teeth
Dental implants
Irregular dental visits
Periodontal disease
Sensitive/painful teeth
Catch food between teeth
Clenching/grinding
Change in bite
Difficulty getting numb
If you have any dental condition not listed in any of the questions, please list here.
Preferred Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
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MEDICAL
Please check any of the following which you have had or have at the present. You must mark each question, please.
Has there been any change in your general health within the past year?
*
YES
NO
If so, please list
Have you been hospitalized or had an operation within the past five years
*
YES
NO
If so, please list
Have you had any serious illness in the last five years?
*
YES
NO
Other
Have you or have you taken a bisphosphonate, including, but not limited to, Boniva, Reclast, and/or Fosamax
*
YES
NO
Have you had abnormal bleeding associated with previous extractions, surgery or trauma?
*
YES
NO
If yes please explain.
Are you allergic or have you reacted adversely to:
*
YES
NO
Local anesthesia
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Iodine
Codeine or other narcotics
Chlorhexidine
Please list current allergies:
Please list current medications:
If you have any medical condition not listed in any of the questions, please list here.
For Women
Are you pregnant, nursing or trying to become pregnant
YES
NO
To the best of my knowledge, the health and dental information presented above is an accurate representation of my or my named minor child’s present health status as of this date. If in the event there is any change in my health status or medications, I will inform Smile Essentials before any treatment is started.
Patient Signature (Parent or Guardian)
*
Date
*
-
Month
-
Day
Year
Date
*
YES
NO
AIDS I HIV Positive
Allergies
Alzheimer‘s Disease
Anemia
Angina / Chest pain
Arthritis
Artificial Joints
Asthma
Bleeding / Bruising
Blood Disease
Cancer
Chemotherapy
Congenital Heart Disease
Convulsions
Diabetes
Difficulty Hearing
Digestive Diseases
Drug Addiction
Emphysema
Fainting or dizziness
Frequent Headaches
Glaucoma
Heart Attack or Disease
Heart Murmur/ Mi tral Valve Prolapse
Heart Surgery
Hemophilia
Hepatitis A. B or C
Allergies (seasonal)
Allergies to medications
*
YES
NO
Hereditary Disease or Deformities
High Blood Pressure
Hospitalization
Hypoglycemia
Jaundice/ Liver Disease
Kidney Disease
Leukemia
Low Blood Pressure
Nervous Problems
Numbness or Tingling Sensations
Oral Herpes/ Cold Sores/ Fever Blisters
Painful or Swollen Joints
Paralysis
Persistent Cough
Psychiatric Care
Radiation Therapy
Shortness of Breath
Sinus Problems
Sleep Apnea
Steroid Therapy
Stroke
Thyroid Disease
Tuberculosis
Tumors or Growths
Ulcers
Venereal Diseases
Vision Changes
Consent for Internet Communications
I grant my permission to Smile Essentials to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured website for Smile Essentials. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand that myself and Smile Essentials are responsible for maintaining the strict confidentiality of any ID and password assigned to me.; and that Smile Essentials is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand Smile Essentials is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use Smile Essentials website with my ID and password. I also agree to immediately notify Smile Essentials of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to their parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that Smile Essentials has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf. I understand that Smile Essentials cannot and does not assume any responsibility for my use or misuse of patient information or other information transmitted, monitored, stored, uploaded, or received using the site or services. By signing this form, I agree that I have read the above information regarding the secured uploading of patient information to the website for Smile Essentials, and grant Smile Essentials permission to securely upload my patient information to the website.
Patient Signature
Patient Guardian Signature (if patient is a minor)
Printed Name:
*
Date
*
-
Month
-
Day
Year
Date
HIPAA Acknowledgement
I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time this authorization may be revoked, when the office that receives this authorization receives a written revocation. That revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to redisclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
Patient Signature
Patient Guardian Signature (if patient is a minor)
Printed Name
*
Date
*
-
Month
-
Day
Year
Date
Cancellation Policy
Everyone is asked to please confirm their appointments at least 48 business hours prior to their scheduled appointment times. If your appointment is on a Monday, cancellation needs to be by the prior Friday at 10:00am. This allows us the ability to make every effort to accommodate other patients. If proper notice is not received, a fee of $100 per appointment hour may be charged for every appointment cancelled or missed.
Patient Signature
Patient Guardian Signature (if patient is a minor):
Printed Name:
*
Date:
*
-
Month
-
Day
Year
Date
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