PATIENT UPDATE
In which office are you seen?
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New Canaan, CT
Somers, NY
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In case of emergency...
Emergency Contact:
First Name
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Contact Number
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DENTAL INSURANCE INFORMATION
Name of Insured
First Name
Last Name
Relation to Patient
Birthdate
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Month
-
Day
Year
Date
Social Security # or Dental Insurance ID#
Employer
Dental Insurance Company
Group #
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MEDICAL HISTORY
Physician's Name
First Name
Last Name
Date of last visit
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Month
-
Day
Year
Date
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
*
Yes
No
Have you had any serious illnesses or operations?
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Yes
No
If yes, describe:
Have you ever had a blood transfusion?
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Yes
No
If yes, give approximate date:
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Month
-
Day
Year
Date
(Women) Are you pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Check ( ✓ ) if you have or have had any of the following:
*
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints, Pins, etc.
Asthma
Back Problems
Bleeding Abnormally
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, Persistent
Cough up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
Hernia Repair
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
NONE
Allergies:
*
List medications you are currently taking and the correlating diagnosis:
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AUTHORIZATION AND RELEASE
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.I certify that I, and/or my dependent(s), have insurance coverage with
Name of Insurance Company (ies)
And assign directly all insurance benefits, if any, otherwise payable to me for services to:
New Canaan Dentistry, Paul Harbottle, DDS
Somers Dental Care, Paul Harbottle, DDS
I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below. . I further understand that I am required to give 24-hour notice to the office if I need to cancel or reschedule an appointment. Failure to do so will result in a cancellation fee being charged to me.
*
Please print first name of Patient, Parent, Guardian or Personal Representative
Please print last name of Patient, Parent, Guardian or Personal Representative
Signature of Patient, Parent, Guardian or Personal Representative
*
Relationship to Patient
Payment is due in full at time of treatment unless prior arrangements have been approved.
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