simplyresultsdentistry.com - Patient Information Form

Patient Information
Date:

MonthDayYear
Date
Patient ID (SSN):
Patient Name:

First NameLast Name
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday:

MonthDayYear
Date
Age:
Sex:

MaleFemale
Marital Status:

MinorSingleMarriedSeparatedWidowedPartneredDivorced
Occupation:
Employer/School:
Employer/School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Name:
Whom may we thank for referring you?
Contact Information
Home:
Please enter a valid phone number.
Cell:
Please enter a valid phone number.
Work:

Area CodePhone Number
Email:
example@example.com
Spouse's Cell:
Please enter a valid phone number.
In Case of Emergency, whom may we contact? (Please specify someone outside your household)
Name:
Relationship:
Home:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Cell:
Please enter a valid phone number.
Dental Insurance Information
Name of Insurance Plan Subscriber:

First NameLast Name
Relationship to Patient:
Insurance Company Name:
Group Number:
Subscriber Birthday:

MonthDayYear
Date
Subscriber ID or SSN:
Are you covered by additional insurance?

YesNo
Name of Subscriber for additional coverage:

First NameLast Name
Relationship to Patient:
Insurance Company Name:
Group Number:
Subscriber Birthday:

MonthDayYear
Date
Subscriber ID or SSN:
Dental History
Reason for today's visit:
Former Dentist:

First NameLast Name
Date of last dental visit:

MonthDayYear
Date
Date of last dental x-rays:

MonthDayYear
Date

Please mark "Yes" or "No" to indicate if you have had any of the following:

	Yes	No
Bad breath
Bleeding gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growth in your mouth

How often do you floss?
How often do you brush?
Health History
Physician Name:
Date of last visit:

MonthDayYear
Date
Are you under a physician's care now?

YesNo
If "Yes" please specify:
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
Have you ever been hospitalized or had a major operation?

YesNo
If "Yes" please specify:
Have you ever had a serious head or neck injury?

YesNo
If "Yes" please specify:
Have you ever responded adversely to medical or dental treatment?

YesNo
If "Yes" please specify:
Have you ever experienced abnormal bleeding with extractions or surgery?

YesNo
If "Yes" please specify:
Do you wear contact lenses?

YesNo

Please mark "Yes" or "No" to indicate if you have had any of the following:

	Yes	No
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, Persistent or Bloody
Diabetes
Emphysema
Epilepsy
Fainting or Dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
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 Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or Growth on Head / Neck
Ulcer
Weight Loss, Unexplained
Venereal Disease

Hepatitis:

YesNo
Hepatitis Type:
Women:
Are you pregnant?

YesNo
Due Date:

MonthDayYear
Date
Are you Nursing?

YesNo
Taking birth control pills?

YesNo
Medications
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name:
Phone Number:
Please enter a valid phone number.
Are you taking Bisphosphonates?

YesNo
Allergies: Please indicate if you are allergic to any of the following:

AspirinBarbiturates (Sleeping pills)CodeinelodineLatexLocal AnestheticPenicillinSulfaOther allergies (please specify):
Acknowledgement: Receipt of Dental Materials Fact Sheet.

I acknowledge I have received a copy of the Dental Materials Fact Sheet
I certify that I, and/or my dependent(s), have insurance coverage with the above named insurance company(ies) and assign directly to Dr. James Hernandez 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 whether manual or electronic.

Dr. James I. Hernandez 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 payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Print Name:

First NameLast Name
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient:
Insurance Disclaimer

(Please read carefully)
Our goal is to help you maximize your dental insurance benefits. As a courtesy, we are happy to bill your dental plan for services. When we call on your insurance and verify benefits it is not a guarantee of payment by the insurance company and may vary according to your individual plan when the actual claim is submitted.

Any treatment plan that our office proposes to you is an estimate of what your insurance coverage will be, it is not a guarantee. If you need exact payment of benefits, then a pretreatment is required. If you would like this done, you must notify our office staff before any work is initiated. (This could take approximately 6-8 weeks). (Initial)

Please remember that the contract itemizing your dental benefits is between you, your employer, and your insurance company. Regardless of coverage, your estimated co-payment is due in full the day of treatment. Also remember dental insurance plans are not designed to cover all of your dental needs.

I, Name , have chosen to allow Dr. James I. Hernandez to file my insurance and accept full responsibility for this account and for all dentistry performed upon my family in this dental office. I understand it is my responsibility to be aware of what type of dental plan I have. I also understand this office cannot guarantee my insurance company will cover all services rendered and it is only an estimate of benefits. I also understand that if my insurance company does not pay within 120 days of my date of service then I will become responsible to pay at this time. I am also aware that there a out-of-pocket cost of $150 for cancellations with less than 24hr notice.
Print Name

First NameLast Name
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Patient Information

Contact Information

Dental Insurance Information

Dental History

Health History

Women:

Medications

Insurance Disclaimer