Cloud Family Dental Patient Information

Patient Information

John Cloud, DDS | Jordan Thompson, DDS | Michael Kinard, DDS
Date

MonthDayYear
Date
Name

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Social Security #
Email
example@example.com
If patient is a minor, give parent or guardian's name.
How did you hear about our office?
Responsible Party Information
Name

First NameLast Name
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Home Phone Number
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Address, if less than 3 years.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Birthdate

MonthDayYear
Date
Relationship to Patient
Employer
Occupation
No. Years Employed
Social Security #
Birthdate

MonthDayYear
Date
Work Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Insured's Name

First NameLast Name
Insured's Social Security #
Insurance Company
Group #
Subscriber ID #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Do you have dual coverage?
Insured's Name
Insured's Social Security #
Insurance Company
Group #
Subscriber ID #
Insurance Company's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Employer
Emergency Information
Name of nearest relative not living with you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I understand that where appropriate, credit bureau reports may be obtained.
Signature
Welcome! So that we may provide you with the best possible care please complete all questions on this medical/dental form. All information is completely confidential.
What is the reason for your visit today?
Date of Last Dental Exam

MonthDayYear
Date
Last Dental Cleaning

MonthDayYear
Date
Last Full Mouth X-rays

MonthDayYear
Date
What was done at your last dental visit?
Previous Dentist's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What dental aids do you use? (Interplak, Toothpick, Etc)
Do you have any dental problems now?
If yes, please describe.
Are any of your teeth sensitive to:
Hot or cold?
Sweets?
Biting or chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters, or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to become caught in between your teeth?
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Smoke/chew tobacco?
Have you ever had:
Orthodontic treatment?
Oral surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
If so, please describe, including cause.
Have you experienced:
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches, or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with your teeth's appearance?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?
If yes, please describe.
Is there anything else about having dental treatment that you would like us to know?
Have you been under the care of a medical doctor during the past two years?
If yes, for what?
Physician's Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you taken any medication or drugs during the past two years?
Are you taking any medication, drugs, or pills now?
If yes, please list name and dosage.
Are you aware of having an allergic (or adverse reaction) to any medication or substance?
If yes, please list.
Have you been a patient in the hospital during the past five years?
Indicate which of the following you have had, or have at present by selecting yes or no.
Heart (surgery, disease, attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (hip, knee, etc)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact Lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (infectious) B (serum)
Venereal Disease
A.I.D.S.
HIV Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care
Do you use more than two pillows to sleep?
Have you lost or gained more than 10 pounds in the past year?
Do you have or have you had any disease, condition, or problem not listed?
If yes, please list:
Women....Are you...
Pregnant?
If yes, how many months?
Nursing?
Taking birth control pills?
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
Signature
Date

MonthDayYear
Date
Acknowledgement of Privacy Practices

Cloud Family Dental
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Confirm appointments by text message?
Confirm appointments by email?
Email
example@example.com
With whom may we share your Protected Health Information?
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Cloud Family Dental strives to provide the best dental care at the most fair and reasonable cost to our pateints. If you have dental insurance, we will file your dental claim as a courtesy. We will attempt to collect all that is legally due from your insurance company.

We will do our best to provide an accurate estimate of what insurance may pay, but cannot guarantee that your insurance will pay.

Most claims will be processed using the insurance's usual, customary, and reasonable fees, but due to the numebr of new policies within many of the existing networks, we cannot guarantee that your policy dictates as a fee write off will be honored, especially when treatment is down coded, denied completely, or your yearly benefits have been used.

I am aware that my dental insurance fee adjustment and write offs may not apply to my dental treatment and I agree to pay all fees to Cloud Family Dental regardless of what insurance remits.
Signature
Date

MonthDayYear
Date
Printed name if signed on behalf of the patient:
Appointment No Show & Cancellation Disclosure
Patients who are not able to keep their appointments are asked to provide timely notice of cancellation or need to reschedule prior to their appointment. Unfortunately, in recent months our "no show" rate for appointments has significantly increased. This has created multiple challenges, but most importantly, it is compromising our ability to provide care for our patients who need to be seen in a timely manner.

We will send automatic appointments reminders via text and telephone calls based on your communication preferences, but it is ultimatley your responsibility to remember your appointment date and time. If you give us less than a 24 business hour notice you will be charged a $75 cancellation fee.

NO SHOW
A "no show" is defined as a scheduled appointment where you fail to arrive, or you are greater than 15 minutes late.

LATE CANCELLATION
A "late cancellation" is defined as a scheduled appointment that you fail to provide 24 business hour notice of the cancellation. After the 3rd late cancellation, the provider reserves the right to dismiss care.

Please sign and date below, acknowledging recognition of this policy.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Patient Information

Acknowledgement of Privacy Practices

Appointment No Show & Cancellation Disclosure