PDF: Adult Patient Form for Pauly Dental

  • We warmly welcome you to our office. Please take a few moments to complete the following information so that we can better care for you. It is our goal to help you reach and maintain maximum oral health.
  • Circle one:
  • Gender*
  • Birth date*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Last Visit
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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

     
     
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental Insurance

  • Primary Dental Insurance

  • Format: (000) 000-0000.
  • Insured’s Birth date
     / /

  • Secondary Dental Insurance

  • Format: (000) 000-0000.
  • Insureds Birth date
     / /

  • 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.

     
     

  • Medical History

  • Your current physical health is:*
  • Are you currently under the care of a physician?*
  • Are you taking any prescription/over the counter drugs?
  • Do you use or smoke tobacco in any form?
  • Have you or do you take medication for osteoporosis?
  • For women: Are you taking birth control pills?
  • Are you pregnant?
  • Have you ever had head or neck trauma?
  • Do you wear a night guard?
  • Have you ever had any of the following diseases or medical problems?*
  • Are you allergic to any of the following items?

  • Dental History

  • Are your teeth sensitive to:
  • Do you have any fear of dental work?
  • Have you been diagnosed with sleep apena?
  • How would you describe the condition of your teeth and gums?
  • Are you currently in pain or discomfort with your teeth or gums?
  • Do your gums bleed when you brush?
  • Do your gums bleed when you floss?
  • Have you ever experienced pain in you jaw joint?
  • Have you ever been treated for TMJ symptoms?
  • Do you grind or clench your teeth?
    1. 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.
    2. 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.
    3. 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.
    4. I understand that where appropriate, credit bureau reports may be ordered.
    5. I understand that it is my responsibility to advise your office of any changes in the information obtained.
    6. I authorize the use of my social security number to file my dental claims.
     
     
     
     
     
  • Date*
     / /
  •  
  • Should be Empty: