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Gustusdental.com

Comprehensive Family Dentistry
Mark A. Gustus, D.D.S.

Please comPlete the following confidential information
I N S U R A N C E
Date _________________________________________________________ PRIMARy CARRIER
Insurance Co. __________________________________ Name________________________________________________________ Employee Name _______________________________ Address ______________________________________________________ Employer _______________________________________ City ___________________ State _____________ Zip ______________ Group # _______________________________________ Home Phone # _______________________________________________ Birth Date ______________________________________ Business Telephone ____________________________ Ext.___________ ➧ Cell Phone # _________________________________________________ Date Employed ________________________________ SS# or ID# ____________________________________________________ ID# ____________________________________________ Birthdate _____________________________________________________ SECONDARy CARRIER
Married____ Single____ Divorced____ Widowed____ Child____ Insurance Co. __________________________________ Employee Name _______________________________ Employer _______________________________________ Group # _______________________________________ A C C O U N T I N F O R M A T I O N
Birth Date ______________________________________ Date Employed ________________________________ ID# ____________________________________________ ________________________________________________________________________________________________________________ yOUR:
Name _________________________________________________
Occupation ____________________________________________ Employer _______________________________________________ G E T T I N G T O K N O W y O U
Business Address ________________________________________City _______________________State _____ Zip______________ Purpose of this appointment ________________________ Is another member of your family, or relative a patient yOUR SPOUSE:
at our office? ______________________________________ Name _________________________________________________ Referred to us by ___________________________________ Occupation ____________________________________________ ____________________________________________________ Employer _______________________________________________ ____________________________________________________ Business Address ________________________________________ Person to contact for emergency ___________________ City _______________________State ______ Zip______________ _______________Phone ______________________________ Business Telephone _______________________Ext. _________ Closest relative not living with you ___________________ _______________Phone ______________________________ H E A L T H H I S T O R y
1. Do you have pain from any area of your mouth? 3. My last physical examination was on_____________________________________________________________________4. Are you now under the care of a physician? _____________________________________________________________ Yes _______ No ________ Physician’s Name _______________________________________________________________________________________ Address __________________________________________________________________________________ Phone # _______________________________ 5. Have you been hospitalized or had a serious illness within the past 5 years? 6. Are you now taking any medication, drugs or pills? If yes, please list those drugs: ____________________________________________________________________________ ________________________________________________________________________________________________________ 7. Are you allergic or have you reacted adversely to any of the following medications: (Please circle if yes) 8. Are you aware of being allergic to any other medication or substance? 9. Have you ever had: (Please circle if yes) Mitral Valve Prolapse (MVP) Radiation Therapy AIDS (Acquired Immune Deficiency Syndrome) 10. Do you smoke? Yes ___________No _____________________ How Much? ____________________________________11. Do you have any disease, condition or problem not listed above that you think we should know about? If yes, explain? ___________________________________________________________________________________________ DENTAL HISTORy
12. Date of last dental examination __________________________________________________________________________
13. Have you had orthodontic treatment? (Braces)
14. Do your gums bleed when brushing your teeth? 15. Have you ever been told you have pyorrhea (gum disease)? 16. Have you ever had professional instructions on dental home care? 17. Is any part of your mouth sensitive to temperature, or pressure? If yes, where? ____________________________________________________________________________________________ 19 Do you have any unpleasant odor, or taste, in your mouth? 20. Do you have any pain or soreness around the eyes, or ears? 21. Are you dissatisfied with your teeth and their appearance? FOR WOMEN ONLy

Yes _________ No __________ If yes, What month? ________ CONSENT:
The undersigned hereby authorizes Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed
appropriate by Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all
forms of treatment, medication and therapy, that may be indicated in connection with (Name of Patient)
_______________________________________________ and further authorize and consent that Doctor choose and employ such assistance
as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that 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. I understand
that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry our
treatment, payment activities and health care operations. Please understand that failure to pay any unpaid balance in a timely manner
may result in collection and attorney fees.
Signature ______________________________________________________________________ Relationship to Patient __________________________________________________________

Source: http://www.gustusdental.com/PDF/forms.pdf

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