Angel Smiles Dental Hygiene Care

Angel Smiles Dental Hygiene Care
ANGELICA VILLEGAS INDEPENDENT REGISTERED DENTAL HYGIENIST
180 Westheights Drive

Kitchener, Ontario N2N 1J9

Phone: (519)576-4537 / (519)5SMILES
Personal title

Mr.Miss.Ms.Mrs.
Full name
Today's date
MM
DD
YR
Date of birth
MM
DD
YR
Age
Home Address
Apt #
City
Province
Postal Code
Home Tel
Cellphone
Email Address
example@example.com
Occupation
Employer
Family Dr
Telephone
Address
How did you hear about Angel's Smiles:

FamilyFriendYPCo-worker
Co worker
Other
Insurance information
Is this patient covered by insurance?

YesNo
Primary Insurance Subscriber name
Date of birth
MM
DD
YR
Patient relationship to subscriber

SelfSpouseChildOther
Name of secondary insurance (if applicable)
Subscriber name
Policy #
Cert #
Employer
Occupation
Work Tel
Emergency Contact
Tel
Relationship
OFFICE POLICY REGARDING INSURANCE: Your dental insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. The responsibility of payment ultimately lies with the patient, not the insurance company. As a courtesy, we will file your claim on your behalf. / understand that I am required to pay my "Estimated Patient Portion" and any deductible due to Angel' Smiles at the time of my visit. Failure to provide our office with all the information necessary to file your insurance claim will require full payment at the time of service. Any portion of treatment that the insurance does not cover is the patient's responsibility. A statement will be sent to the patient for any balance which is not paid by the insurance company. / hereby authorize the release of any dental information that is needed to file my insurance. / consent to treatment for myself/family under 18 years old. / have read the above statements and understand that I AM RESPONSIBLE FOR PAYMENT IN FULL AFTER (30) DAYS OF MY TREATMENT,

REGARDLESS OF ANY DELAY IN PAYMENT(S) BY MY INSURANCE COMPANY.
Signature

Clear
Date: MM 1/DD/YYYY

MonthDayYear
Date
I understand that I am responsible for making full payment for my treatment whether or not I have dental insurance.
Patient/Parent or Guardian Signature

Clear
Date: MM/DD/YYYY

MonthDayYear
Date
HEALTH HISTORY
Have you ever had an unfavorable reaction following Dental treatment?
Have you ever had an unfavorable reaction following Dental treatment?

YesNo
If Yes, specify
Have you ever had excessive bleeding requiring a special treatment?

YesNo
LIST OF ALLERGIES
LIST OF MEDICATION
Do you have or have you had any other medical problems?
Female patients: are you or could you be pregnant or Nursing?

YesNo
If pregnant mm
Check any of the following which you have or had:

Heart trouble/anginaHeart murmurAsthmaDiabetesArthritisCongenital Heart defectStrokeHemophiliaEpilepsyGlaucomaVenereal DiseaseArtificial valve, joint orprosthesisAnemiaRheumatic feverLupusNervous disordersCortisone treatmentCancer treatmentMigraine/HeadacheEmphysemaHepatitis A-B.C ORJaundiceOsteoporosisKidney diseaseFainting spellsSinus problemsNeck injuryPsychiatric TreatmentAddictionTMJ ProblemsHIV & or AIDSStomach ulcerSickle cell diseaseLiver diseaseThyroid diseaseAlcoholismCardiac PacemakerMitral valve prolapseBlood transfusionsTuberculosis TBHigh blood pressure
Smoker? Y or N
Do you have any dental concerns?

YesNo
If Yes, specify
Date of last Dental Hygiene visit
How often do you Brush?
Floss?
DENTAL HISTORY
Are you pleased with the appearance of your teeth?

Yesno
Are you currently experiencing any dental discomfort?

YesNo
Is any part of your mouth sensitive to the following

HotColdBitingSweetsOther
Do you have any

ImplantsRoot canal treatmentsCrownsOrthodontics
Consent to treatment

I certify that I have read, understood and accurately completed the personal medical and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding my medical and dental histories. As may be required, I consent to my physician being contacted regarding any specific medical question. I authorize the Dental Hygienist to perform necessary diagnostic procedures and treatment as required to achieve the proper level of oral hygiene treatment-care and to share my information with any dental practitioner if needed. I understand that I am financially responsible for the dental hygiene services provided even if my insurance coverage may not be inclusive.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE DENTAL HYGIENE SERVICES PROVIDED EVEN IF MY INSURANCE COVERAGE MAY NOT BE INCLUSIVE.
Signature: Patient/Parent/guardian.

Clear
Date

MonthDayYear
Date
Should be Empty:

Angel Smiles Dental Hygiene Care

ANGELICA VILLEGAS INDEPENDENT REGISTERED DENTAL HYGIENIST

HEALTH HISTORY

DENTAL HISTORY