Patient Contact Information
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Apt/Unit
City
Postal Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work
Please enter a valid phone number.
Format: (000) 000-0000.
Cell
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Please Select
Home Phone
Work
Cell
Email
Emergency Contact Person
Preferred Contact Method
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Primary Insurance Company
Name of Policy Holder
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Group Policy/ Plan Number
I.D./Certificate Number
Employer
Name of Insurance Company
Secondary Insurance Company (if applicable)
Name of Policy Holder
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Group Policy/ Plan Number
I.D./Certificate Number
Employer
Name of Insurance Company
I, understand, certify that I (or my dependent) have insurance coverage and assign directly to Drs. Bishara-Margolian DPC 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 hereby authorize Drs. Bishara-Margolian to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Authorized Signature:
*
* All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all insurance information. We do not have access to your private insurance policy information unless provided to us.
Referral Information
How did you hear about us?
Website
Internet
Yellow Pages
Referral
Family Member or Friend
Other
Dental History
Please check any of the following that may apply to you
Sensitivity
Grinding or clenching teeth
Tooth Pain or Discomfort While Chewing
Bleeding, swollen or irritated gums
Headaches, earaches, or neck pain
Loose or shifting teeth
Jaw Joint Pain (clicking/cracking)
Bad breath or taste in the mouth
Broken Teeth or Fillings
When was your last dental visit
What was done at that visit
When having dental treatment do you require sedation
nitrous oxide (laughing gas)
oral medication
Do you smoke or chew tobacco?
Yes
No
If "yes" for how long
Medical History
Please check any of the following that apply to you:
AIDS
Diabetes
High Blood Pressure
Rheumatic Fever
Allergies
Emphysema
HIV Positive
Seizures
Anaemia
Excessive Bleeding
Jaundice
Snoring/Sleep Apnea
Arthritis
Fainting
Kidney Disease
Stomach Problems
Artificial Joints
Glaucoma
Liver Disease
Stroke
Asthma
Heart Conditions
Low Blood Pressure
Thyroid Disease
Blood Disorders
Heart Murmur
Pacemaker
Tuberculosis
Cancer
Heart Disease
Pregnant
Ulcers
Chemotherapy
Hepatitis A, B or C
Respiratory Problems
Other
Do you have any allergies
Aspirin
Codeine
Penicillin
Sulpha Drugs
Local Aesthetic
Latex
Other
Do you have any joint replacements?
Are you currently under a physician's care?
Yes
No
For?
Physician's Name and Phone Number
Pharmacy's Name and Phone Number
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize Drs. Bishara-Margolian and their staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: