K Smile Dental

K Smile Dental

Patient Information
PATIENT INFORMATION
SS/HIC/Patient ID #
Date
Patient Name*

First NameLast Name
Sex

MFI prefer not to say
Parent Name (if patient is a minor)

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Emergency Contact*
E-Mail *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MarriedWidowedSingleMinorSeparatedDivorced
Patient Employer/School
Occupation
Type a question
Employer/School Phone
Spouse's Name
Birthdate
DENTAL HISTORY
Do your gums bleed when you brush?*

YesNo
Are your teeth sensitive to heat or cold?*

YesNo
Date of last dental examination*

MonthDayYear
Date
How would you describe your current dental problem?
Are you having pain or discomfort at this time?*

YesNo
Have you been a patient in a hospital in the past two years?*

YesNo
Have you been under the care of a Medical Doctor in the past two years?*

YesNo
Are you taking any medication or drugs?*

YesNo
Are you sensitive or allergic to any medication or anesthetics?*

YesNo
If yes please list.
Indicate which of the following you have had or have at present.*

Bad breathBleeding gumsBlisters on lips or mouthBurning sensation on tongueChew on one side of mouthCigarette, pipe, or cigar smokingClicking or popping jawDry mouthFingernail bitingFood collection between the teethForeign objectsGrinding teethGums swollen or tenderJaw pain or tirednessLip or cheek bitingLoose teeth or broken fillingsMouth breathingMouth pain, brushingOrthodontic treatmentPain around earPeriodontal treatmentSensitivity to coldSensitivity to heatSensitivity to sweetsSensitivity when bitingSores or growths in your mouth
How often do you floss?
How often do you brush?
Are you pregnant?*

YesNo
What month?
Are you nursing?

YesNo
Are you taking birth control?

YesNo
1. The undersigned hereby authorizes doctor to take x-rays, study models, photographs, or any other diagnostic aides deemed appropriate by doctor to make a thorough diagnosis of the patients dental needs.

2. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment.

3. I understand that all responisbility for payment for dental services provided in this office for myself or my dependents is mine. Due and payable at the time services are rendered unless other arrangements have been made in the event payments are not recieved by the agreed dates, I understand that a 1-1/2% finance charge (8% APR) may be added to my account in addition to any collection charges.

4. I understand that where appropriate, Credt Bureau reports may be obtained.

5. I understand that it is my responsibility to advise your office of any changes in the infrmation contained in this form.
HEALTH HISTORY
Physician's Name

First NameLast Name
Date of last visit

MonthDayYear
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).

YesNO
Place a mark on "Yes" or "No" to indicate if you have had any of the following:
Arthritis, Rheumatism

YESNO
Artificial Heart Valves

YESNO
AIDS/HIV

YESNO
Anemia

YESNO
AIDS/HIV

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Artificial Heart Valves

YESNO
Type a question

Type option 1Type option 2Type option 3Type option 4
This is a fill in the blanks field. Please add appropriate blank fields and text.
Patient signature*

Clear
DENTAL INSURANCE
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #
Is patient covered by additional insurance?

YesNo
Subscriber's Name
Birthdate
SS#
Relationship to Patient
Insurance Co.
Group #
ASSIGMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company and assign directly to Dr. First Name Last Name all insurance benefits, if and, otherwise payable to me for services rendered. 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 insurances.

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 or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
This is a fill in the Who is responsible for this account? field. Please add appropriate blank fields and text.
Type a question
Number
Please verify that you are human*
Should be Empty:

K Smile Dental

PATIENT INFORMATION

DENTAL HISTORY

HEALTH HISTORY

DENTAL INSURANCE