KIMBERLY FOON DDS HEALTH HISTORY FORM

Date

Name

First NameMiddle InitialLast Name

Preferred Name

Email

example@example.com

Best Way For Us to Contact You:

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Daytime Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sex:

Age

Date Of Birth

Date

Patient's SSN #

Marital Status

Employed By

Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer's Business Phone

Please enter a valid phone number.Format: (000) 000-0000.

Spouse's Name (If Applicable)

First NameLast Name

Spouse is Employed By (If Applicable)

Whom May We Thank For Referring You?

Name of Dental Insurance Company

Subscriber Name

Subscriber Date of Birth

Date

Subscriber SSN #

Subscriber ID #

Subscriber Group #

Emergency Contact Name & Relation

Emergency Contact's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you happy with the appearance and function of your teeth and mouth? Explain:

Do you have pain in your mouth or jaw joint? Please explain:

Principal reason for today's visit:

HAVE YOU EVER TAKEN BISPHOSPHONATES? IF YES, EXPLAIN.

PLEASE LIST ALL ALLERGIES-(e.g. PENICILLIN, LATEX, METALS)

HAVE YOU EVER TAKEN PHEN-FEN DIET PILLS? IF YES, EXPLAIN.

HAVE YOU BEEN HOSPITALIZED IN THE LAST TWO YEARS? IF YES, EXPLAIN.

ARE YOU CURRENTLY UNDER CARE OF A PHYSICIAN? IF YES, WHOM?

PLEASE LIST ALL MEDICATIONS YOU ARE TAKING

DO YOU USE, OR HAVE YOU USED TOBACCO IN ANY FORM?

DO YOU SMOKE OR VAPE? IF YES, EXPLAIN.

PLEASE MARK YES TO EACH OF THE FOLLOWING CONDITIONS WHICH YOU HAVE HAD:

PLEASE EXPLAIN CONDITIONS MARKED YES PREVIOUSLY

PLEASE LIST ALL SIGNIFICANT CONDITIONS NOT LISTED PREVIOUSLY

WOMEN: ARE YOU, OR MIGHT YOU BE PREGNANT?

THE ABOVE INFORMATION IS COMPLETE TO THE BEST OF MY KNOWLEDGE AND IS ONLY FOR USE IN MY TREATMENT, BILLING AND PROCESSING OF INSURANCE FOR BENEFITS TO WHICH I AM ENTITLED. I WILL NOT HOLD MY DENTIST OR ANY MEMBER OF THEIR STAFF RESPONSIBLE FOR ANY ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS MEDICAL HISTORY.

CONSENT: I HEREBY GIVE GENERAL CONSENT TO RECEIVE APPROPRIATE DENTAL TREATMENT OR ADVICE FROM DR. KIMBERLY FOON AND/OR HER AUXILIARIES AND ASSOCIATES. I UNDERSTAND THAT I AM FREE TO ASK QUESTIONS ABOUT MY TREATMENT. I UNDERSTAND THAT I MAY BE REFERRED TO AN APPROPRIATE SPECIALIST FOR TREATMENT AND/OR CONSULTATION.

SIGNATURE

DATE

Date

ALL FEES ARE CONSIDERED DUE AND PAYABLE FROM THE TIME THEY ARE CHARGED. IF IT IS NOT POSSIBLE TO PAY THE FULL AMOUNT AT ONE TIME, SPECIAL PAYMENT ARRANGEMENTS MAY BE MADE. IN SOME CASES, INTEREST WILL BE CHARGED ON OUTSTANDING BALANCES.

AS A CONVENIENCE, WE ACCEPT VISA, MASTERCARD, AND DISCOVER CARDS. WE WILL ASSIST YOU IN FILLING OUT AND SUBMITTING DENTAL INSURANCE FORMS. IT SHOULD BE NOTED THAT ALL FEES ARE ULTIMATELY THE RESPONSIBILITY OF THE PATIENT OR RESPONSIBLE PARTY REGARDLESS OF THE AMOUNT OF PAYMENT MADE BY THE INSURANCE COMPANY. WE WILL HOLD AS CREDIT OR REIMBURSE ANY AMOUNT THAT IS OVERPAID.

INITIALS

ACKNOWLEDGEMENT OF RECEIPT OF HIPPA PRIVACY POLICY.

SIGNATURE

DATE

Date

Dental Insurance

Medical History

-FINANCIAL POLICY-