Patient Information

Please click on the links below to quickly and easily fill out the form before your visit. Thank you!

 

New Patient Form:

https://www.ident.ws/template_include/new_patient_sign_in.do?site=14096&practiceId=30169

 
Name
Name
INSURANCE
Is policy connected with your union?
Do you have dual coverage? If yes, please complete the secondary insurance information.
DENTAL INFORMATION
Do your gums bleed when you brush?
Are your teeth sensitive to heat or cold?
Are your teeth sensitive to pressure?
Are your teeth sensitive to sweets?
Do you grind or clench your teeth?
Do you have any fear of dental work?
Have you been hospitalized or had a serious illness within the last two years?
Are you now under the care of a physician?
Have you ever taken pre-medication for dental appointments?
DO YOU OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK YES OR NO.
Hepatitis
Diabetes
Epilepsy
Abnormal Heart Condition
Heart Murmur
Biophosphates (Osteoporosis Meds)
Heart Attack
Stroke
Kidney Disease
High Blood Pressure
Rheumatic Fever
Asthma
Abnormal Bleeding
Mitral Valve Prolapse
HIV / AIDS
Nervous Disorder
TB
Radiation Therapy
Ulcer
Phenfen / Redux
ARE YOU ALLERGIC TO ANY OF THESE MEDICATIONS? PLEASE CHECK YES OR NO.
Codeine
Aspirin
Metal or Nickel Allergies
Sulfa Drugs
Local Anesthetic (Lidocaine, Novacaine, Xylocaine)
Erythromycin
Penicillin
Latex
Methyl Methacrylate
Are you presently wearing an artificial prosthesis of any kind? (Artificial hip, heart valve, artificial knees?
WOMEN ONLY
Are you pregnant?
Are you taking birth control pills?
If yes, please be advised that any antibiotics prescribed may interfere with your birth control pills and alternative means of contraception should be utilized.
There will be a $40.00 charge for broken appointments without 24 hour notice.
To avoid misunderstanding regarding your dental insurance, we wish our patients to know ultimately all patients are personally responsible for payment of fees. we will be happy to assist you with completing insurance forms. After payment has been received from your insurance company a statement will be mailed to you for any additional balance.
I hereby authorize payment directly to the above named dentist of the group insurance benefits otherwise payable to me and the release of any information relating to this claim.
I hereby grant authority to the dentist in charge of my care to administer any treatment, to administer such anesthetics and perform such operations as may be deemed necessary in the diagnosis and treatment of my case. I also understand it is very important to report any changes in my medical or dental status to the dentist at the earliest time, and I agree to do so. I give permission to the dentist to obtain from my physician any additional information regarding my medical history needed to provide me the best treatment possible.
Date
Date
Thank you! Patient, do not write below this line.
Date
Date
 
Lorett color band 1 lg.jpg