Online Patient Information Form Is patient covered by additional insurance?
I certify that I, and/or my dependent(s), have insurance coverage with
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 authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the
above-named Insurance Company(ees) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.
Date of last dental visit Date of last dental X-rays PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:
Blisters on lips or mouth
Cigarette, pipe or cigar smoking
Burning sensation on tongue
Chew on one side of mouth
Food collection between teeth
Loose teeth or broken fillings
Sores or growths in your mouth
Are you allergic to any of the following:
Are you under a physician's care now?
Are you taking any pills, medication or drugs?
Are you on a special diet?
Have you ever been hospitilized or had a major operation?
Do you take, or have taken, Phen-Fen or Redux?
Have you ever had a serious head or neck injury?
Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?
Do you use controlled substances?
DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?
Cold Sores/Fever Blisters
Congenital Heart Disorder
Fainting Spells/Dizziness
Stomach/Intestinal Disease