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Welcome to our office

WELCOME TO OUR OFFICE
Thank you for filling out this form accurately and completely. The information you provide will help us serve your dental healthcare needs more effectively and efficiently. If you have any questions at anytime, please ask – we are always happy to help!
PATIENT INFORMATION
Name___________________________________________________________________Male____Female____
Minor______ Single______Married______ Divorced______ Separated______Widowed________
Mailing Address________________________________City,ST________________ Zip________
Birthdate_____________ E-Mail Address_____________________________________________
SS#_______________________Home Ph#__________________Cell#_____________________
Employer_________________________________________________Occupation_______________
Business Street Address__________________________City_________________ Zip_________
How Long at this job?_______________________ Wk Phone_____________________________
Children Only:School______________________________Grade_________________________
SPOUSE INFORMATION
Name_______________________________________ Occupation________________________
Employer____________________________________Wk Phone__________________________
Business Street Address________________________ City________________Zip____________
RESPONSIBLE PARTY
Person Responsible for Payment____________________________________________________
Relationship to Patient__________________________ ___Phone__________________________
Street Address________________________________City___________________Zip__________
Business Address _______________________________Wk Phone________________________

INSURANCE INFORMATION
Name of Insured_________________________________________________________________
Relationship to Patient____________________Soc Sec # of Insured________________________
Birthdate of Insured_______________________Group# _________________________________
Insurance Co_______________________________Employer_____________________________
If more than one insurance company, please complete the following:
Name of Insured_________________________________________________________________
Relationship to Patient____________________Soc Sec # of Insured________________________
Birthdate of Insured_______________________Group#__________________________________
Insurance Co___________________________Employer_________________________________
GETTING TO KNOW YOU
Is another member of your family or relative a patient in our office?
Name____________________________________Relationship____________________________
Referred to Us By________________________________________________________________
Person to Contact for Emergency_____________________________Phone#________________
Former Dentist__________________________________Last Appt_________________________
Medical Doctor__________________________________________________________________
Is there anything about the appearance of your teeth that you don’t like?(color,shape, size,
spaces,cracks, chips, alignment, other________________________________________________

HEALTH HISTORY

PLEASE CIRCLE YES OR NO
Yes No Are you currently taking ANY medications? If so, please list:
_______________________________________________________________________
Yes No Are you allergic to penicillin, aspirin, or codeine? (Circle applicable ones)
Yes No Are you allergic to any other drugs or medication?
List ___________________________
Yes No Have antiresorptive drugs (Fosamax,Boniva, Zometa, etc) been given in the past five
years?
Yes No Are you under treatment of a medical doctor? If so, state reason:

_________________________________________________________________________
Yes No Do you smoke or chew tobacco?
Yes No Have you ever had excess bleeding requiring treatment?
Yes No Are you currently bleaching your teeth?
WOMEN PLEASE CIRCLE YES OR NO
Yes No Is there a possibility you may be pregnant?
Yes No Are you nursing?
Yes No Are you taking birth control pills?
NOTE: Antibiotics (such as penicillin, erythromycin, etc.) and some medications may alter the effectiveness of birth
control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CIRCLE YES OR NO
Yes No Heart Disease or Attack
Yes No Sexually Transmitted Disease Yes No Artificial Heart Valve Yes No Epilepsy or Convulsions Yes No Heart Pacemaker Yes No Fainting or Dizzy Spells Yes No Angina or Chest Pain Yes No High/Low Blood Pressure Yes No Asthma/Hayfever/Emphysema
Yes No Hemophilia Yes No Sinus Trouble
Yes No Kidney Trouble Yes No Diabetes (TYPE __________)
Yes No Dialysis Yes No Artificial Joints
Yes No Hepatitis (Type___________) Yes No Cancer

Yes No Cortisone Medicine Yes No Chemotherapy/Radiation Yes No Pain in Jaw Joints FEES AND PAYMENTS
We make every effort to keep down the cost of your dental care. You can help by paying upon completion of each
visit (Cash, Check, Credit Card, or CareCredit-a special dental credit card.) An ESTIMATE of the charge for any
procedure can be given to you.
Please remember that insurance is filed as a courtesy to our patients. Some companies pay fixed allowances for
certain procedures and others pay a percentage of the charge. IT IS YOUR RESPONSIBILITY TO PAY ANY
DEDUCTIBLE AMOUNT, CO-INSURANCE, OR ANY OTHER BALANCE NOT PAID FOR BY YOUR INSURANCE
COMPANY. If the patient’s portion of the dental bill is not paid within 25 days of the monthly billing date, a late charge
of 0.5% per month will be assessed.
I authorize the dentist to release any information including the diagnosis and the records of any treatment or
examination rendered to me or my child during the period of such dental care to third party payers and/or other health
practitioners.
This signature on file is my authorization for the release of information necessary to process my claim. I hereby
authorize payment directly to the dentist named of the insurance benefits otherwise payable to me.
Signature_________________________________________________Date____________

Source: http://www.arbuckledental.net/assets/docs/FORM.pdf

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