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1Office Policies
2Patient Information
3Insurance Information
4Medical History
5Dental History

Welcome To Our Dental Office

We welcome you to our dental office and we thank you for choosing us as your dental provider.
Please read the following information to familiarize yourself with our office.
The personal information provided below will be protected and kept private by our office. All information will be used and disclosed responsibly according to the Privacy Act standards set up and monitored by our office.

Our Office Policy

We want you to achieve the highest level of dental care. We know that each individual has different needs and expectations and promise to provide you with options allowing you, the patient, to make the final decision.

Appointments

Appointments are reserved exclusively for you. As a courtesy to other patients, please be advised that we do require two business days for any changes to your appointment or a charge will be incurred.

Payment

Our services are to be paid on the day of treatment. For your convenience our office accepts Visa, MasterCard, Debit, American Express and cash. Should there be a problem, alternative arrangements must be made ahead of your appointment.

Dental Insurance

Many of our patients have some form of dental insurance. Our office will do anything we can to help you maximize your dental benefits. We are happy to submit your dental claims electronically on your behalf. In addition, for your convenience, we accept payment directly from your insurance company. You, the patient, are responsible for any differences not covered by your insurance company. Please remember that the government Privacy Act does not allow dental offices to access your insurance information. Insurance companies will only provide information to the patient.

Consent(Required)
Full Name:(Required)
Select:(Required)
Address:
Are you likely to be available on short notice for future appointments?
Person responsible for this account:(Required)

Name:
Address:

Primary Insurance

Date of Birth:
Relation:

Are you familiar with your Plan details?

Secondary Insurance

Date of Birth:
Relation:

Are you familiar with your Plan details?
Method of Payment:

Medical History

All information is confidential

The following information is required by the dentist to assist in proper diagnosis and treatment.

Have you ever had a serious illness requiring hospitalization or extensive medical care?(Required)
Are you presently under the care of a physician?(Required)
Have you had a medical examination in the last year?(Required)
Do you use any prescription or non-prescription drugs regularly?(Required)
Do you have any allergic conditions: eg. hay fever, skin rash, food allergies, metal, latex?(Required)
Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?(Required)
Have you been hospitalized in the last 5 years?(Required)
Have you ever experienced any unusual reaction to any of the following?(Required)
Have you been warned against taking any drug or medication?(Required)
Do you bruise easily or bleed abnormally?(Required)
Do you require pre-medication for dental treatment?(Required)
Have you ever had any organ implants or medical implants?(Required)
Have you ever fainted?(Required)
Do your ankles swell?(Required)
Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?(Required)
Do you have frequent headaches?(Required)
Do you have AIDS, or have you ever tested positive for HIV?(Required)
Do you have any of the following?(Required)
Please check all that apply.
Have you had any injury, surgery or x-ray therapy to your face or jaw?(Required)
Do you have any disease, condition, or problem that you think the doctor should know about?(Required)
WOMEN ONLY - Are you pregnant or suspect you might be?(Required)
WOMEN ONLY - Are you taking birth control pills?
WOMEN ONLY - Are you nursing?

Dental History

Reason for today's visit:(Required)
Are you presently having dental pain?(Required)
Is there a dental problem you would like to take care of as soon as possible?(Required)
How frequently do you see your dentist?(Required)
Do your gums bleed easily?(Required)
Are your teeth sensitive to:(Required)
Do you feel you have bad breath at times?(Required)
Have you ever had jaw joint surgery?(Required)
Do you have pain in your jaw joints or suffer from migrain headaches?(Required)
Does any part of your mouth hurt when clenched?(Required)
Does your jaw crack or pop when opened widely?(Required)
Have you had:(Required)
Do you grind or clench your teeth during the day or night?(Required)
Do you smoke?(Required)
Do you or does any family member have a problem with snoring?(Required)
Have you ever experienced any growths or sore spots in your mouth?(Required)
Previous problems with dental treatment?(Required)
Are you satisfied with the appearance of your teeth?(Required)
Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.


Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment, we will require 2 business days notice, otherwise a charge of $50 will be applied to your account for time lost.


Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contracted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.
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