Smile Questionnaire

Smile Questionnaire

In order to better serve our patients, we place emphasis on helping you determine your present and future oral health goals. The following are some items we will discuss during your dental visit. Please answer the following questions as best as possible.
DateTime
Name*

First NameLast Name
Do you have any areas of concern?*
Are you pleased with the current state, health and appearance of your teeth and smile? Yes or NO*
Explain*
How long has it been since your last cleaning? *
Have you been treated for or told you have periodontal disease (gum disease)? Yes or No*
Are you happy with the current color of your teeth? Yes or No*
Would you like your teeth to be straighter? Yes or No*
Do you clench or grind your teeth? Yes or No*
What do you NOT like about your smile?*
Has fear prevented you from seeking dental care? Yes or No*
Who may we thank for your referral? *
Please check all that apply:*

Bleeding GumsGag ReflexLoose TeethBad BreathMissing TeethSensitive TeethOther

General Dentistry Informed Consent
Dentist*

First NameLast Name
Patient Name*

First NameLast Name
WORK TO BE DONE: I understand that I am having the following work done [Indicate all services being provided]:*

FillingsBridgesCrownsX-RaysExtractionsImpacted teeth removalRoot CanalsDenturesOther
Patient Initials*
DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications may cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock. I have advised my dentist of any and all medications I am currently taking, including but not limited to prescription medications, over-the-counter medications, herbal remedies, and alternative medications. I further understand that failure to advise that failure to advise my dentist of any medications I am taking prior to starting to dental work may have unforeseen negative consequences for me.
Patient Initials*
CHANGES lN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discoverable during previous examinations. For example, root canal therapy may be necessary following routine restorative procedures. I give my pcnnission to my dentist to make any/all changes and additions as necessary.
Patient Initials*
REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.), and I authorize the dentist to remove the following teeth: * and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved with extraction, some of which arc pain, swelling, spread of infection, dry socket, and loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time, and fractured jaw. I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my responsibility.
Patient Initials*
CROWNS, BRIDGES AND CAPS: I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the pennanent crowns are delivered. I realize the final opportunity to make changes in my new crowns, bridge, or cap (including shape, fit, and color) will occur only before final cementation. It is also my responsibility to return for pcnnanent cementation within 21 days from initial tooth preparation. Excessive delays may allow for tooth movement which may necessitate a remake of the crown, bridge, or cap. In such instances, I understand that therl.! will be additional charges for remakes due to my delaying permanent cementation.
Patient Initials*
ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee that root canal therapy will save my too.th, and that complications can occur from the treatment, and that occasionally root canal filling material may extend through the tooth which does not necessarily afTect the success of the treatment. I understand that cndodontic files are very fine instruments and stresses from their manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicocto·my). I understand that the tooth may be lost in spite of all efforts to save it.
Patient Initials*
PERIODONTAL LOSS (TISSUE AND BONE): I understand that if I am being treated for periodontal disease, this means I have a serious condition, causing gum and bone inflammation or loss and that it can ultimately lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that any dental procedure may have a future adverse effect on my periodontal condition.
Patient Initials*
FILLINGS: I understand that care must be taken when chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that increased sensitivity is a common effect of a newly placed filling.
Patient Initials*
DENTURES: I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems associated with dentures. Immediate dentures (placement of denture immediately after extractions) may be painful. In addition, immediate dentures often require considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delay of 30 days or more, there may be additional charges assessed against me.
Patient Initials*
I understand that dentistry is an inexact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment(s) which I have requested and authorized.

I hereby authorize any of the doctors or dental assistants or auxiliaries to proceed with and perfonn the dental restorations and treatments indicated above and as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosed circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I may be responsible for payment of the dental fees.
Signature of Patient: *

Clear
DateTime
INTERNAL USE
Signature of Dentist:

Clear
Date

Cancellation and No-Show Policy
Office hours are by appointment and we do value your time. This office is a private practice dental office and not a dental "clinic." Appointment time is reserved for you alone. Where appropriate, we prefer to schedule longer appointments so we can complete as much needed dental treatment as possible during one appointment. We feel this type of scheduling will cause minimal disruption to your dally schedule and will provide efficiency in completing your dental care. When you make an appointment, please be sure that you will be able to keep it. Morning appointments may be best for more complicated procedures.

Emergencies and unforeseen patient treatment problems may arise, causing schedule changes. Emergencies are unexpected and seem to come at the most inconvenient times. If you have a dental emergency that needs immediate attention, we will always offer to see you at once. We expect that other patients who might be slightly inconvenienced by this will be understanding of the situation. At some point, they may need the same courtesy too.

Like many offices, this office does call to confirm your appointment. Please make a note of any dental appointments we have scheduled in a place where you will be easily reminded. If you cannot make an appointment as scheduled, please notify the office. There will be a charge of $45 per 30 minutes of scheduled time for a broken appointment or cancellation with less than 24 hours' notice for your appointment. This fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred with out the payment of this fee. Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $45 cancellation fee will be charged. If you have any questions about our appointment cancellation and no-show policy, please feel free to ask us.

I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
I, First Name Last Name , have received a copy of Patriot Family Dental's Appointment Cancellation Policy.
Signature*

Clear
DateTime
Should be Empty:

General Dentistry Informed Consent

Cancellation and No-Show Policy