3289 Greyling Drive
San Diego, CA 92123
Tel: (858) 292-1155
Fax: (858) 292-1177
Joanne C. Vargas-Velasco, DMD, DC  

Patient Information

TODAY’S DATE:




 Male  Female





 Single   Married   Domestic Partnership   Separated   Divorced   Widowed













EMERGENCY CONTACT (Relative or Friend not living with you)





PRIMARY INSURANCE INFORMATION

 Yes  No





 
SECONDARY INSURANCE INFORMATION

 Yes  No






I affirm that the information I have given is correct to the best of my knowledge.  I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover.  I hereby authorize the dentist to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all my insurance submissions, whether manual or electronic.  
 
Date:
 

 DENTAL HISTORY

Why have you come to the dentist today:
Are you currently in Pain?  Yes   No
Do you Require Antibiotics before dental treatment?  Yes   No
Your Current dental health is  Good   Fair   Poor  
Do you floss daily  Yes   No
Type of bristles on your tooth brush?  Hard   Medium   Soft
Do you use an electric toothbrush?  Yes   No
How long do you use a toothbrush before replacing it?
Do you use anything in addition to your brush and floss?  Yes   No
If yes, what?
Would you like fresher breath  Yes   No
Whiter Teeth?  Yes   No
Do you have pain/discomfort in your jaw/joint (TMJ/TMD)?  Yes   No
Do your gums ever bleed?  Yes   No
Do your gums ever Itch?  Yes   No
Have you ever had periodontal surgery?  Yes   No
Do you have mobility in your teeth?  Yes   No
Are your teeth sensitive to hot and cold?  Yes   No
Do you still have wisdom teeth?  Yes   No
If yes, Why?
Previous Dentist:
Last Visit Date:
Why did you leave your previous Dentist?
Are you happy with the way your smile looks?  Yes   No
If not, what would you change?
 

 MEDICAL HISTORY

ARE YOU UNDER A PHYSICIAN’S CARE CURRENTLY?  Yes   No
Physician’s Name:
Physician’s Address:
Physician’s Phone:
FOR WOMEN:
Are you Pregnant?  Yes   No    Unsure
Taking Oral Contraceptives?  Yes   No
Nursing?  Yes   No
 
Have you ever been hospitalized or had a major operation?  Yes   No   If yes, please explain:  
Have you ever had a serious head or neck injury?  Yes   No   If yes, please explain:  
Are you taking any medications, pills, or drugs?  Yes   No   If yes, please list:  
Do you take, or have you taken Phen-Fen or Redux?  Yes   No   If yes, please explain:  
Do you take, or have you taken, Fosomax, Boniva, Actonel?  Yes   No   If yes, please explain:  
Are you on a special diet?  Yes   No   If yes, please explain:  
Do you use tobacco?  Yes   No   If yes, please explain:  
Do you use controlled substances?  Yes   No   If yes, please explain:  
 
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING:  Yes   No
 Aspirin  Acrylic  Codeine  Latex  Local Anesthetics
 Metal  Penicillin  Sulfa Drugs  Other:

Do you have, or have you ever had any of the following?  
AIDS/HIV Positive  Yes   No
Anaphylaxis  Yes   No
Anemia  Yes   No
Arthritis  Yes   No
Artificial Heart Valve  Yes   No
Artificial Joint  Yes   No
Asthma  Yes   No
Blood Transfusion  Yes   No
Breathing Problem  Yes   No
Cancer  Yes   No
Chemotherapy  Yes   No
Chest Pains  Yes   No
Cold Sore/Fever Blisters  Yes   No
Congenital Heart Disorder  Yes   No
Cortisone Medication  Yes   No
Diabetes  Yes   No
Drug Addiction  Yes   No
Emphysema  Yes   No
Epilepsy or Seizures  Yes   No
Fainting Spells/Dizziness  Yes   No
Frequent Cough  Yes   No
Glaucoma  Yes   No
Gout  Yes   No
Hay Fever  Yes   No
Heart Attack/Failure  Yes   No
Heart Murmur  Yes   No
Heart Pace Maker  Yes   No
Hemophilia  Yes   No
Hepatitis  Yes   No
Herpes  Yes   No
High Blood Pressure  Yes   No
Hypoglycemia  Yes   No
Irregular Heartbeat  Yes   No
Kidney Problems  Yes   No
Liver Disease  Yes   No
Lung Disease  Yes   No
Mitral Valve Prolapse Yes  No
Psychiatric Care Yes  No
Radiation Treatments Yes  No
Renal Dialysis Yes  No
Rheumatic Fever Yes  No
Scarlet Fever Yes  No
Shingles Yes  No
Sickle Cell Disease Yes  No
Sinus Trouble Yes  No
Stomach/Intestinal Disease Yes  No
Thyroid Disease Yes  No
Tonsilitis Yes  No
Tuberculosis Yes  No
Tumors or Growths Yes  No
Ulcers Yes  No
Have you ever had any serious illness not listed above?  Yes   No
If yes, please eplain: 
Comments
To the best of my knowledge, the questions on this form have been accurately answered.  I understand that providing incorrect information can be dangerous to my (or patient’s) health.  It is my responsibility to inform the dental office and staff of any changes in medical status.  
 
Signature: Date:
 
Relationship to Patient:  Self    Parent    Guardian
   Name (If the patient is a minor): 
 

 CONSENT FOR TREATMENT

 

I hereby authorize doctor or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of (name of patient) dental needs.

Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance to provide proper care.

I agree to the use of anesthetics, sedatives and other medication necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for complete recital of any possible complications.

Lastly, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% late charge (18% APR) may be added to my account. Any balance over 120 days past due will be sent to a collections agency.

 
Signature: Date:
 
Relationship to Patient: Self   Parent   Guardian
   Name (If the patient is a minor): 
 
DRUGS, MEDICATIONS AND SEDATION

I understand that antibiotics, analgesics and other medications can cause reactions causing redness and swelling of the tissues, itching, vomiting, and/or anaphylactic shock (severe allergic reaction) and can cause pain. They may cause drowsiness and lack of awareness and coordination, which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous devices for at least 12 hours or until fully recovered from the medications and drugs that may have been given to me in the office. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection and pain and potential resistance to effective treatment of my condition.

Initials

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that was not discovered during examination, the most common is being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

Initials

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of this office’s Notice of Privacy Practices.

Click here to view the Notice of Privacy Practices

Signature of Patient (Parent or Guardian)

ACKNOWLEDGEMENT OF RECEIPT OF DENTAL MATERIALS FACT SHEET

I have received a copy of the Dental Materials Fact Sheet.

Click here to view the Dental Materials Fact Sheet

Signature of Patient (Parent or Guardian)

Appointment Policy

I understand that I will call and give at least 48 hours notice for any changes or cancellation to my appointment to avoid a charge of $65 per hour for the reserved time. All Cancellation Fees must be paid prior to scheduling another appointment.

Signature of Patient (Parent or Guardian)

 CONSENT FOR TEXTING AND ONLINE COMMUNICATION

We provide our patients the option to participate in our online patient communication system. We use this information to provide you with excellent service. Some of the features include the ability to:

  • Request Appointments
  • Online Confirm Appointments via Email
  • Receive Text Message Appointment Reminders
  • Submit Patient Satisfaction Surveys
  • Refer Your Friends Online
 

You may opt-out of your communications at any time by clicking the unsubscribe link found in the footer of each email or by replying to a text message with 'STOP'. Standard Text Messaging rates apply.

Patient's First Name:     Patient's Last Name:  


 
Relationship to Patient: Self   Parent   Guardian
   Name (If the patient is a minor): 



 
 Options (one or both):    
 Check here if you want Text Messages   Cell Phone:
 Check here if you want E-mails   E-mail Adress: 





 
 Please check box if you decline Texting and Online Communication and complete below.
I, ,decline Texting and Online Communication for office use.





 
 
Signature: Date:


 

 Photography Release

I, ,

hereby authorize Dr. Vargas-Velasco or her assistants to take photographs, slides, and/or videos of my face, jaws, mouth, and teeth.

I understand that the photographs, slides, and/or videos will be used as a record of my care, and may be used for educational purposes in study club meetings, lectures, seminars, demonstrations, and professional publications (journals, magazines).

I further understand that if the photographs, slides, and/or videos are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential.

I do not expect compensation, financial or otherwise, for the use of these photographs.

 
 
Signature: Date:
 
 Please check box if you decline photography for office use and complete below.
I, ,decline to have photographs taken.




 
 
Signature: Date: