www.pineycreekdental.com - Patient Information Form

  • Patient Information

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  • How did you hear about Piney Creek Family Dentistry?

  • Primary Dental Insurance

  • Do you have secondary dental insurance?

  • Secondary Dental Insurance

  • Assignment and Release

  • And assign directly to Piney Creek Family Dentistry and its associates all insurance benefits, if any, 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 insurance submissions.

    Piney Creek Family Dentistry and its associates may use my health care information and may disclose such information to the above-named company and their agents for the purpose of obtaining payment of services and determining insurance benefits of the benefits payable for related services.

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  • Contact Information

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

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Please check all that apply

  • Health History

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  • Have you ever taken any medications containing bisphosphonates? This includes brands such as Fosamax, Actonel, Didronel, Boniva, Aredia and Zometa.*
  • Have your had Botox?*
  • Have your ever had Dermal Fillers?*
  • Do you snore?*
  • Do you wear a CPAP?*
  • Have you ever been diagnosed with obstructive sleep apnea?*

  • Please answer "Yes" or "No" to the following

  • AIDS / HIV*
  • Anemia*
  • Arthritis, Rheumatism*
  • Artificial Heart Valves*
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  • Artificial Joints / Joint?*
  • Asthma*
  • Back Problems*
  • Bleeding abnormally, with*
  • Extractions or surgery?*
  • Blood Disease*
  • Cancer*
  • Chemical Dependency*
  • Chemotherapy*
  • Circulatory Problems*
  • Congenital Heart Lesions*
  • Cortisone Treatments*
  • Cough, persistent / bloody*
  • Diabetes*
  • Dizziness*
  • Emphysema*
  • Epilepsy*
  • Fainting*
  • Glaucoma*
  • Headaches*
  • Heart Murmur*
  • Heart Problems*
  • Hepatitis*
  • Herpes*
  • High Blood Pressure*
  • Jaundice*
  • Jaw Pain*
  • Kidney Disease*
  • Liver Disease*
  • Low Blood Pressure*
  • Mitral Valve Prolapse*
  • Nervous Problems*
  • Pacemaker*
  • Psychiatric Care*
  • Radiation Treatment*
  • Respiratory Disease*
  • Rheumatic Fever*
  • Scarlet Fever*
  • Shortness of Breath*
  • Sinus Trouble*
  • Skin Rash*
  • Special Diet*
  • Stroke*
  • Swollen Feed / Ankles*
  • Swollen Neck / Glands*
  • Thyroid Problems*
  • Tonsillitis*
  • Tuberculosis*
  • Tumor or growth on head or neck*
  • Ulcer*
  • Venereal Disease*
  • Weight loss / Gain*
  • Do you wear contact lenses?*
  • Are you taking birth control pills?*
  • Are you pregnant?*
  • Are you nursing?*

  • Medications

  • Allergies

  • Consent

  • The undersigned herby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is contract between the insurance carrier and me and not between the instance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account or refunded to me if I have paid the dental fees incurred. I further understand that a late charge may be added to any overdue balance. I understand that, where appropriate, credit reports may be obtained.

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