Patient Information (Confidential)

E-mail Address:

Name:              

Nickname:        

Home Phone:    

Work Phone:    

Cell Phone:      

Address:          

City:                 State: Zip:

Soc. Sec. #     

Birth Date:      

Male  Female 

Employer:      

Emergency Contact Name:

Emergency Contact Phone:

 

 

How would you like to be reminded of your appointment:  E-mail  Text  Cell  Work  Home

Marital Status:  Single  Married  Divorced  Widowed  Separated

How did you hear about our office?  Insurance  Internet  Mailer  Referral
Whom may we thank for the referral?

Insurance Company: Subscriber ID # Group # Phone #
Secondary Ins. Co.:   Subscriber ID # Group # Phone #

Responsible Party Information:  Self  Other (fill out next 3 line items)

Name of person responsible for this account:

Soc. Sec.#

Relationship to Patient: Birth Date:

Phone#

Address: Employer:

 

Authorization Statement and HIIPA Privacy Notice:

I hereby authorize Drs. David and Jeana Conner DDS to provide dental services to me and my dependants and apply for benefits on my behalf for covered services rendered. I request that the payments from my insurance company be made to the above named corporation and/or provider(s). I certify that the information that I have provided above is correct and further authorize the release of any necessary information including medical, dental and insurance coverage information to my insurance company in order to determine my insurance benefits to which I may be entitled. I authorize the provider to initiate a complaint to the Insurance Commissioner for any reason on my behalf. A photocopy of this assignment shall be considered as effective and valid as the original, this authorization may be revoked at any time in writing. I understand and agree that (regardless of my dental insurance status or coverage), I am ultimately responsible for the balance on my account and my dependents for any dental services rendered. If my account becomes past due I agree to pay all costs of collections and litigations if any. I understand that if my account is delinquent I will be charged an additional 33% to cover collection expenses. I have read this entire sheet and have completed the above answers. I certify that this information is true and correct to the best of my knowledge and I will notify Drs. David and Jeana Conner DDS of any changes in my status or the above information.

SIGNATURE OF PATIENT, PARENT OR GUARDIAN 

DATE

HIPPA STATEMENT

I have read and agree with Drs. David and Jeana Conner DDS’s HIPPA Notice of Privacy Policy. I hereby authorize Drs. David and Jeana Conner DDS to furnish to my insurance company or authorizing agency information regarding my protected health information for the purposes of treatment, payments, or health care operations. I further authorize the dentist(s) of Drs. David and Jeana Conner DDS to consult as needed in their sole discretion with other medical providers regarding my medical care.

SIGNATURE OF PATIENT, PARENT OR GUARDIAN  DATE
 

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Patient Medical History

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 impact on dental treatment. Thank you for answering the following questions.

Current Physician Name & Phone #: Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Have you ever had joint replacement? Do you take, or have you taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any other medication containing Bisphosphonates? Are you on a special diet? Do you use tobacco?   Do you use any controlled substances? Are you taking any medications, pills or drugs?

No Yes Are you currently under their care?    No  Yes, for what:   No  Yes, what occurred:    No  Yes, if yes, when?:  No  Yes, for how long:    No  Yes, for how long:  No  Yes, which type:  No  Yes, how much daily ,                  weekly    No  Yes, which ones:    No  Yes, which ones:

 

Women: Are you...  Pregnant  Trying to conceive  Nursing  Taking hormonal contraceptives (oral, patch, or other )

Please indicate if you are allergic to any of the following:
 Aspirin  Penicillin  Codeine  Acrylic  Metal  Latex  Local Anesthetics  Sulfa Drugs  Other: 

Please indicate if you have, or have you had, any of the following:

Aids/HIV Positive  Chest Pains  Frequent Headaches  Irregular Heartbeat  Scarlet Fever  Alzheimer’s Disease  Cold Sores/Fever Blisters  Genital Herpes  Kidney Problems  Shingles  Anaphylaxis  Congenital Heart Disease  Glaucoma  Leukemia  Sickle Cell Disease  Hypoglycemia

Anemia  Convulsions  Hay Fever  Liver Disease  Sinus Trouble  Angina  Cortisone Medicine  Heart Attack/Failure  Low Blood Pressure  Spinal Bifida  Arthritis/Gout  Diabetes  Heart Murmur*  Lung Disease  Stomach/Intestinal Disease  Rheumatism

Artificial Heart Valve*  Drug Addiction  Heart Pace Maker*  Mitral Valve Prolapse*  Stroke  Artificial Joint*  Easily Winded  Heart Disease  Osteoporosis  Swelling of Limbs  Asthma  Emphysema  Hemophilia  Pain in Jaw Joints  Thyroid Disease

Blood Disease  Epilepsy Or Seizures  Hepatitis A  Parathyroid Disease  Tonsillitis  Blood Transfusion  Excessive Bleeding  Hepatitis B Or C  Psychiatric Care  Tuberculosis  Breathing Problem  Excessive Thirst  Herpes Radiation Treatments  Tumors or Growths

Bruise Easily  Fainting/Dizziness  High Blood Pressure  Recent Weight Loss  Ulcers  Cancer  Frequent Cough  High Cholesterol  Renal Dialysis  Venereal Disease  Chemotherapy  Frequent Diarrhea  Hives or Rash  Rheumatic Fever*  Yellow Jaundice

 

Have you ever had a serious illness not listed above?  Yes  No  N/A
Comments:
* Condition may require medication. N/A – Not answered by patient
 2007 American Heart Association Guidelines do not require prior to most procedures. Notify us if you have a special situation.

Patient Dental History

Name of Previous Dentist and Location  Date of Last Exam:

Describe your immediate dental concern:

YES NO Do your gums bleed while brushing your teeth?                                                                                   Are your teeth sensitive to hot or cold liquids/foods?                                                                           Are your teeth sensitive to sweet or sour liquids/foods?                                                                      Do you feel pain in any of your teeth?                                                                                                 Do you have any sores or lumps in or near your teeth?                                                                        Have you had any head neck or jaw injuries?                                                                                      Have you ever experienced any of the following problems in your jaw?                                                            Clicking                                                                                                                                           Pain (joint, ear, side of face)                                                                                                              Difficulty in opening or closing                                                                                                           Difficulty in chewing

YES NO Do you have frequent headaches?                                                                                      Do you clench or grind your teeth?                                                                                      Do you bite your lips or cheeks frequently?                                                                          Have you ever had any difficult extractions?                                                                        Have you ever had any prolonged bleeding following extractions?                                          Have you had any orthodontic treatment?                                                                            Do you wear dentures or partials?                                                                                       If yes, date of placement:   Have you ever received oral hygiene instructions regarding the care of your teeth and gums?  Do you like your smile?

 

I certify that I have read and understand all of the above and that I have answered all of the questions accurately. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me, or my child, during the period of such dental care to third party payors and/or health practitioners. I hereby authorize Dr. David and Jeana Connor and theyr staff to examine, take x-rays, and do any necessary treatment. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedure or dental treatments performed.

SIGNATURE OF PATIENT, PARENT OR GUARDIAN
DATE