www.richfloresdental.com - Patient Information Form 

  • PATIENT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • Date of your last dental visit and dental cleaning
     - -

  • DENTAL INSURANCE INFORMATION

  • MEDICAL INFORMATION

  • Format: (000) 000-0000.
  • Are you in good health?*
  • Any changes in your health in the past year?*
  • Are you now under the care of a physician?*
  • Have you had a serious illness, operation or been hospitalized in the past 5 years?*

  • MEDICAL HISTORY

  • JOINT REPLACEMENT: Have you had an orthopedic total joint replacement? ( hip, knee, elbow)*
  • Are you taking or scheduled to begin taking either of the meidcations, Alendronte (Fosamx) or Risedroate (Alctonel) for osteoporosis or Paget's disease?*
  • Do you use tobacco products? (smoking, snuff, chew)*
  • If so, how interested are you in stopping? (Select one)*

  • WOMAN ONLY

  • Are you pregnant?*
  • Nursing?*
  • Are you taking birth control?*
  • Since 2001, were you treated, or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget'sdisease, multiple myeloma or metastatic cancer?*

  • Please select your response to indicate if you have or have not had any of the following diseases or problems

  • Artificial ( Prosthetic) Heart Valve*
  • Previous Infective Endocarditis*
  • Diabetes*
  • Liver Disease*
  • Persistent swollen glands in neck*
  • Severe Headaches / Migraines*
  • Cardiovascular Disease*
  • Congestive Heart Failure*
  • Pacemaker*
  • High Blood Pressure*
  • Low Blood Pressure*
  • Rheumatic Heart Disease*
  • Epilepsy*
  • Mental Health Disorder*
  • Osteoporosis*
  • Autoimmune Disease*
  • Rheumatoid Arthritis*
  • Systemic Lupus*
  • Asthma*
  • Stroke*
  • GI Reflux / Heartburn*
  • Angina*
  • Heart Attack*
  • Anemia*
  • AIDS or HIV Infection*
  • Mitral Valve Prolapse*
  • Bronchitis*
  • Emphysema*
  • Sinus Trouble*
  • Sexually Transmitted Disease*
  • Tuberculosis*
  • Cancer*
  • Kidney Problems*
  • Eating Disorder*
  • Thyroid Problem*
  • Ulcers*
  • Arteriosclerosis*
  • Heart Murmur*
  • Hemophilia*
  • Arthritis*
  • Rheumatic Fever*
  • Hepatitis*
  • Neurological Disorder*
  • Others not listed ...*
  • Date*
     - -

  • This is our new Financial Agreement that is in effect as of March 1, 2021

  • Please read, initial and sign at the bottom stating that you agree to our office policy.

  • All previous information is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

  • I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

  • I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behold of my dependents (if any), within 30 days of treatment. Any payments not received within the 30 days will result in a 10% interest charge that will be charged every 30 DAYS until the balance is paid in full.

  • I understand that if I do not provide a 24 HOUR notice for cancelling an appointment, I will be charged a fee of 95.00. Your time is valuable, just as ours is.

  • Date*
     - -
  • Should be Empty: