Patient Information

Please allow 5 - 10 minutes to complete the form. We recommend you use this online form, but if you prefer to print it out, please click here.

* = required

Title

First Name*

Middle Name or Initial

Last Name*

Preferred Name

Gender*

Male Female

Marital Status

Height

Weight

Date of Birth*

Current Age*

Social Security number

Driver's License number

Address

Address*

City*

State*

Zip*

Do you have a different billing address?

Yes No

Billing Address

Billing City

Billing State

Billing Zip

Contact Information

Home Phone*

Mobile Phone

Work Phone

Email*

Best time & number to contact you*

Emergency contact name and phone number*

Name of Referring Dentist

Insurance Information

By providing the information below, we can review your insurance plan before you arrive to maximize your benefits.

Employer of Insurance Holder

Employer Phone of Insurance Holder

Insurance Company

Insurance Company Phone

Policy number

Group number

Do you have secondary insurance?

Yes No

Secondary Insurance

Employer of Secondary Insurance Holder

Employer Phone of Secondary Insurance Holder

Secondary Insurance Company

Secondary Insurance Company Phone

Secondary Policy number

Secondary Group number

Medical History

Name of Personal Physician & Office Address

Personal Physician Phone Number

Rate your overall health*

Excellent

Good

Fair

Poor

Our office offers Oral Conscious Sedation and IV Sedation services. Would you be interested in learning more about our Sedation Dentistry services?

Nitrous Conscious Sedation IV Sedation Not interested

Medical History - Women Only

Are you taking Birth Control or Hormones?

Yes No

Are you pregnant?

Yes No

If pregnant, what is your delivery date?

Possibly pregnant or trying to get pregnant?

Yes No

Are you nursing?

Yes No

Select the following drugs you have used at any time:*

Actonel

Aredia

Bisphosphonate

Boniva

Didronel

Fosamax

Skelid

Zometa

None of the Above

Do you have Jaw Discomfort or TMJ?*

Yes No

Do you have or have you ever had any of the following

Heart problems*

Yes No

Chest pain*

Yes No

Shortness of breath*

Yes No

High blood pressure*

Yes No

Low blood pressure*

Yes No

Heart murmur*

Yes No

Heart valve problem*

Yes No

Taking heart medication*

Yes No

Rheumatic fever*

Yes No

Pacemaker*

Yes No

Artificial heart valve*

Yes No

Frequent nosebleeds*

Yes No

Abnormal bleeding*

Yes No

Blood disease (anemia)*

Yes No

Ever require a blood transfusion*

Yes No

Allergy problems*

Yes No

Hay fever*

Yes No

Sinus problems*

Yes No

Asthma*

Yes No

Intestinal problems*

Yes No

Ulcers*

Yes No

Weight gain or loss*

Yes No

Special diet*

Yes No

Constipation/Diarrhea*

Yes No

Kidney or bladder problems*

Yes No

Bone or joint problems*

Yes No

Arthritis*

Yes No

Back or neck pain*

Yes No

Joint replacement*

Yes No

Diabetes*

Yes No

What is your HA-1C Score

Date of your score

Please use mm/dd/yyyy format

Is it controlled?

Yes No

Family history of diabetes*

Yes No

Dry mouth or constantly thirsty*

Yes No

Fainting spells, seizures, epilepsy*

Yes No

Stroke(s)*

Yes No

Frequent or severe headaches*

Yes No

Thyroid problems*

Yes No

Physician required premeds*

Yes No

Cancer or Tumor*

Yes No

Tuberculosis/Respiratory disease*

Yes No

Herpes or other STD*

Yes No

Do you smoke?*

Yes No

Do you drink alcohol?*

Yes No

Use recreational drugs*

Yes No

History of alcohol or drug abuse*

Yes No

Jaundice or liver trouble*

Yes No

HIV +/AIDS*

Yes No

Glaucoma*

Yes No

Narrow angle glaucoma*

Yes No

Slow clotting blood*

Yes No

Do you wear contact lenses*

Yes No

Hemophilia*

Yes No

Emphysema*

Yes No

Lung disease or COPD*

Yes No

Do you have Hepatitis*

Yes No

Which type?

Please select any that apply

Please list any surgeries you have had in the last 5 years with dates

Please list ALL medications you CURRENTLY take (both OTC and Prescription)

Please list ANY medications you have taken in the last year not listed above

Please list all allergies you have

Agreement & Acknowledgment

I have received and read the Notice of Privacy Practices (HIPAA)*

I, the undersigned hereby authorize the Doctor to take radiographs, study models, photographs, records or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent the Doctor to employ any such assistance as he/she deems appropriate under the law. I further authorize the release of diagnosis, radiographs, patient records, treatments or examinations rendered: to my insurance company, consulting professionals and others I approve.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney's and collection fees. Reservations require a great deal of setup and preparation tailored to you and your treatment. Last minute cancellations and missed reservations will be charged $50.00 per half hour scheduled. To avoid this charge, contact our office within 48 hours of your reservation. We do understand, on occasion, last minute things occur. If we both take our commitment to each other seriously, these issues are often avoidable.

I certify that the information given is correct and current. I understand it is my responsibility to notify Terry L. Isom DMD, PC of any changes. I understand if I withhold information regarding allergies, medical conditions, medications, or supplements; I agree not to hold Terry L. Isom DMD, PC or its employees liable in the event of death or injury. I am aware that it is my responsibility to read and understand my own dental insurance policy, including benefits, limitations and exclusions. I understand that filing of insurance claims is my responsibility and may be provided as a service to me and that any agreement for dental coverage is between my insurance company and myself. I understand that an estimated portion is due at time of service and is estimated according to expected coverage, which may not be disclosed nor guaranteed by my insurance company. I understand my portion may be more if my insurance company does not pay the anticipated amount. I also understand that services are rendered independent of insurance reimbursement. Reservations require payment in full unless approved arrangements have been made. Returned checks will be charged $30.

We accept - Visa, Master Card, and Discover; Financing is available OAC.

Signature of Patient (Responsible Party if a minor):*

Legal binding signature. Please type your full legal name.

Financial Guidelines

Welcome to our office. We are committed to providing you with the best dental care and are happy to discuss any concerns you may have at any time. Your clear understanding of our Financial Policy is important to our professional relationship. We recognize that you may have questions relating to our financial and insurance billing practices therefore, we encourage you to ask our staff questions at any time.

We accept Visa, MasterCard, and Discover credit cards in addition to checks and cash. We do have applications available for Care Credit Finance a service thru Health Financial Groups. We can help you with the application in office and you can have an approval within ten minutes, or you can submit the application from the privacy of your home. If you are interested in applying for Care Credit, please let us know prior to any treatment.

Payment is due on the date of service. If you are interested in setting up an appointment that will include a form of sedation we will collect your treatment amount prior to reserving that time. Parents or guardians are responsible for arranging payments for unaccompanied minors prior to their visit.

Insurance is a contract between you and your insurance company. We file claims for you as a courtesy. We do our best to estimate what your co-pay will be for each visit and that co-pay will be due at the time of service. We will try to help you with any questions or problems arising with your insurance claim, ultimately you are responsible for all fees and balances of services rendered not paid by your insurance.

A finance charge of 1.5% per month will be assessed on all balances after 60 days. Delinquent accounts may be referred to our collection agency after 120 days. You will be responsible to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection on the account.

A $30.00 service charge will be assessed for all returned checks.

With my signature below, I acknowledge that I am financially responsible for all charges. If it becomes necessary to use a collection agency for any amount owed on this or subsequent visits, I the undersigned agree to pay for all legal costs and expenses, including reasonable attorney fees. I have reviewed all the above information, understand the policies, and agree to be responsible for myself (or for my minor dependent child/children) and to pay at time of service to Isom Endodontics.

Date:

Patient Waiver

I, , understand that Terry L. Isom, DMD, PC and Terry, L. Isom, DMD are providing medical/dental services to me in exigent circumstances in an attempt to preclude my condition from rapidly worsening to more severe symptoms. I expressly understand and accept the risk associated with COVID-19 as related to being in a public place and receiving the treatment I am seeking from Terry L. Isom, DMD, PC and Terry, L. Isom, DMD. By proceeding with treatment, I hereby unconditionally and irrevocably waive any and all claims, known and unknown, related to COVID-19 that I may have now or in the future against Terry L. Isom, DMD, PC and Terry, L. Isom, DMD.

PLEASE READ THIS AGREEMENT CAREFULLY.

YOU ARE ADVISED TO CONSULT WITH AN ATTORNEY BEFORE SIGNING.

THIS IS A VOLUNTARY RELEASE OF ANY AND ALL KNOWN AND UNKNOWN CLAIMS.

Date: