PDF: Adult Patient Form for Pauly Dental

Circle one:

Name*

I prefer to be called

Gender*

MaleFemale

Birth date*

SSN

Home address*

Hm#

Cell#*

Wk#

Pgr#

Email*

How do you prefer to confirm your appointments*

Employer

Occupation

Whom may we thank for referring you

Other family members seen by us

Previous Present Dentist

Date of Last Visit

Ph#

Physicians Name

Phone

Address

In the event of an emergency, is there someone who lives near you that we should contact?

Name*

Relation*

Wk#*

Hm#

Insurance Co Name

Address

Phone

Group Plan Local or Policy

Insured’s Name

Relation

Insured’s Birth date

Insured’s SSN

Insurance Co Name

Address

Phone

Group Plan Local or Policy

Insureds Name

Relation

Insureds Birth date

Insureds SSN

A note for patients with dental insurance - We will assist you to maximize your insurance benefits, and we are happy to file claims to your insurance carrier and agree to accept payment from any carrier that offers an assignment of benefits, if you desire. We will do our best to calculate your available benefit amount, however, regardless of what your insurance plan pays, you are responsible for all fees.

Your current physical health is:*

GoodFairPoor

Are you currently under the care of a physician?*

YesNo

If yes please explain

Are you taking any prescription/over the counter drugs?

YesNo

If yes please list

Do you use or smoke tobacco in any form?

YesNo

Have you or do you take medication for osteoporosis?

YesNo

For women: Are you taking birth control pills?

YesNo

Are you pregnant?

YesNo

week

Have you ever had head or neck trauma?

YesNo

Do you wear a night guard?

YesNo

Have you ever had any of the following diseases or medical problems?*

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

Are you allergic to any of the following items?

Please list any other drugs you are allergic to

Why have you come to the dentist today?

Are your teeth sensitive to:

HeatColdPressureSweets

Do you have any fear of dental work?

YesNo

Have you been diagnosed with sleep apena?

YesNo

Please explain:

How do you feel about the appearance of your teeth?

How would you describe the condition of your teeth and gums?

GoodFairPoor

Are you currently in pain or discomfort with your teeth or gums?

YesNo

If yes please explain

How often do you brush your teeth?

Floss

Do your gums bleed when you brush?

YesNo

Do your gums bleed when you floss?

YesNo

Have you ever experienced pain in you jaw joint?

YesNo

Have you ever been treated for TMJ symptoms?

YesNo

If yes, please explain

Do you grind or clench your teeth?

YesNo

The undersigned hereby authorizes doctor to order 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 all recommended treatment mutually agreed upon by me, and to use the appropriate medication and therapy indicated for such treatment in connection with the patient named on this form. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1½% finance charge (18% APR) may be added to my account, in addition to any collection charges.
I understand that where appropriate, credit bureau reports may be ordered.
I understand that it is my responsibility to advise your office of any changes in the information obtained.
I authorize the use of my social security number to file my dental claims.

Signature*

Date*

Dental Insurance

Primary Dental Insurance

Secondary Dental Insurance

Medical History

Dental History