Souhegan Valley Dental - Medical History & Patient Info Form

Souhegan Valley Dental

Medical History & Patient Info Form
Date*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
DOB*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone*
Cell Phone*
Email*
example@example.com
Social Security #*
Emergency Contact Information*
What would you prefer to be called*
Who may we thank for this referral?*
Family Physician*
Phone Number*
Dental Insurance Carrier*
ID*
Group #*
Check this box only if the insured person (the person receiving dental service) is the same as above. If not, enter Insured's info below*

Yes, the insured person receiving dental service is the same as above.No, the insured person receiving dental service is not the same as above (enter below)
Name of Insured
Insured's DOB

MonthDayYear
Date
Relationship to Insured
Employer of Insured
Phone Number
Please enter a valid phone number.
Who is financially responsible for this account
Responsible Party's Phone

Cancellations and Financial Responsibility

Appointments are held exclusively for you. You are required to give 48 hours notice of cancellation of an appointment. You can notify us by calling the office or sending an email. Failure to give 48 hours notice will incur an office charge of $50. Emergency cancellations are assessed case by case.

I agree to be responsible for all office fees and applicable co-pays at the time of service. In addition if I have dental insurance and my claim is denied for any reason, including exhausting of benefits or failure to meet a deductible, I will be responsible for payment of unpaid services.
Patients Name*
Signature*

Clear
Parent/Guardian Name*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
Rheumatic Fever
Heart Disease
Heart Murmur (or MVP)
High Blood Pressure
Tuberculosis
Use Oral Contraceptives
Artificial Joint/Heart Valve
History of Endocarditis
Thyroid Disease
Anemia
Asthma
Diabetes
Are you nursing?
Might you be pregnant?
Hepatitis
Radiation Therapy: Head/Neck
Seizure Disorder
Kidney Disease
Venereal Disease
Bleeding Problems
Cancer
AIDS/HIV
Eating Disorders