Cloud Family Dental Patient Information

Patient Information

John Cloud, DDS Michael Kinard, DDS
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #*
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
Work Phone Number
Please enter a valid phone number.
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.
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?

YesNo
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.
I understand that where appropriate, credit bureau reports may be obtained.
Signature*

Clear
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.
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?*

YesNo
If yes, please describe.
Are any of your teeth sensitive to:
Hot or cold?*

YesNo
Sweets?*

YesNo
Biting or chewing?*

YesNo
Have you noticed any mouth odors or bad tastes?*

YesNo
Do you frequently get cold sores, blisters, or any other oral lesions?*

YesNo
Do your gums bleed or hurt?*

YesNo
Have your parents experienced gum disease or tooth loss?*

YesNo
Have you noticed any loose teeth or change in your bite?*

YesNo
Does food tend to become caught in between your teeth?*

YesNo
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?*

YesNo
Bite your lips or cheeks regularly?*

YesNo
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)*

YesNo
Mouth breathe while awake or asleep?*

YesNo
Have tired jaws, especially in the morning?*

YesNo
Smoke/chew tobacco?*

YesNo
Have you ever had:
Orthodontic treatment?*

YesNo
Oral surgery?*

YesNo
Periodontal treatment?*

YesNo
Your teeth ground or the bite adjusted?*

YesNo
A bite plate or mouth guard?*

YesNo
A serious injury to the mouth or head?*

YesNo
If so, please describe, including cause.
Have you experienced:
Clicking or popping of the jaw?*

YesNo
Pain? (joint, ear, side of face)*

YesNo
Difficulty in opening or closing the mouth?*

YesNo
Difficulty in chewing on either side of the mouth?*

YesNo
Headaches, neckaches, or shoulder aches?*

YesNo
Sore muscles (neck, shoulders)?*

YesNo
Are you satisfied with your teeth's appearance?*

YesNo
Would you like to keep all of your teeth all of your life?*

YesNo
Do you feel nervous about having dental treatment?*

YesNo
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?*

YesNo
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?*

YesNo
If yes, for what?
Physician's Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you taken any medication or drugs during the past two years?*

YesNo
Are you taking any medication, drugs, or pills now?*

YesNo
If yes, please list name and dosage.
Are you aware of having an allergic (or adverse reaction) to any medication or substance?*

YesNo
If yes, please list.
Have you been a patient in the hospital during the past five years?*

YesNo
Indicate which of the following you have had, or have at present by selecting yes or no.
Heart (surgery, disease, attack)

YesNo
Chest Pain

YesNo
Congenital Heart Disease

YesNo
Heart Murmur

YesNo
High Blood Pressure

YesNo
Mitral Valve Prolapse

YesNo
Artificial Heart Valve

YesNo
Heart Pacemaker

YesNo
Rheumatic Fever

YesNo
Arthritis/Rheumatism

YesNo
Cortisone Medicine

YesNo
Swollen Ankles

YesNo
Stroke

YesNo
Diet (Special/Restricted)

YesNo
Artificial Joints (hip, knee, etc)

YesNo
Kidney Trouble

YesNo
Ulcers

YesNo
Diabetes

YesNo
Thyroid Problems

YesNo
Glaucoma

YesNo
Contact Lenses

YesNo
Emphysema

YesNo
Chronic Cough

YesNo
Tuberculosis

YesNo
Asthma

YesNo
Hay Fever

YesNo
Latex Sensitivity

YesNo
Allergies or Hives

YesNo
Sinus Trouble

YesNo
Radiation Therapy

YesNo
Chemotherapy

YesNo
Tumors

YesNo
Hepatitis A (infectious) B (serum)

YesNo
Venereal Disease

YesNo
A.I.D.S.

YesNo
HIV Positive

YesNo
Cold Sores/Fever Blisters

YesNo
Blood Transfusion

YesNo
Hemophilia

YesNo
Sickle Cell Disease

YesNo
Bruise Easily

YesNo
Liver Disease

YesNo
Yellow Jaundice

YesNo
Neurological Disorders

YesNo
Epilepsy or Seizures

YesNo
Fainting or Dizzy Spells

YesNo
Nervous/Anxious

YesNo
Psychiatric/Psychological Care

YesNo
Do you use more than two pillows to sleep?

YesNo
Have you lost or gained more than 10 pounds in the past year?

YesNo
Do you have or have you had any disease, condition, or problem not listed?

YesNo
If yes, please list:
Women....Are you...
Pregnant?

YesNo
If yes, how many months?
Nursing?

YesNo
Taking birth control pills?

YesNo
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*

Clear
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.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Confirm appointments by text message?*

YesNo
Confirm appointments by email?

YesNo
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*

Clear
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*

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Patient Information

Acknowledgement of Privacy Practices

Appointment No Show & Cancellation Disclosure