Patient Information
Patient Name: ______________________________________________________ Date: _____________
Last
First
MI
# Male
# Female
Nickname:_______________________________________________ Birth Date: ___________________________
Phone (Home): ______________ (Work): ______________ Ext: ______ Best time to call: ___________
Preferred appointment: # Morning # Afternoon # Evening # Any Time # M # T # W # T # F # S
Address: _____________________________________________________________________________
Street
Apartment #
__________________________________________________________________________________________________________
City
State
Zip Code
Health Information
Have you ever had any of the following? Please check those that apply:
# ADD
# Cerebral Palsy
# Heart Murmur
# ADHD
# Chicken Pox
# Hepatitis
# AIDS
# Convulsions
# Jaundice
# Allergies ____________ # Diabetes
# Kidney Disease
____________ # Dizziness
# Latex Allergies
# Anemia
# Epilepsy
# Learning Disability
# Artificial Joints
# Excessive Bleeding
# Liver Disease
# Asthma
# Fainting
# Measles
# Autism
# Growths
# Mental Disorders
# Bladder Problems
# Head Injuries
# Mononucleosis
# Blood Disease
# Hearing Problems
# Penicillin Allergy
# Cancer
# Heart Disease
# Respiratory Problems
•
•
•
•
•
•
# Rheumatic Fever
# Sinus Problems
# Stomach Problems
# Stroke
# Thyroid Disease
# Tuberculosis
# Tumors
# Other _______________
_______________
Have you ever had any complications following dental treatment? # Yes # No
If yes, please explain: ____________________________________________________________________
Have you been admitted to a hospital or needed emergency care during the past two years? # Yes # No
If yes, please explain: ____________________________________________________________________
Are you now under the care of a physician? # Yes # No
If yes, please explain: ____________________________________________________________________
Name of Physician: _________________________________________ Phone: ______________________
Do you have any health problems that need further clarification? # Yes # No
If yes, please explain: ____________________________________________________________________
Do you currently take any medications? # Yes # No
If yes, please list them: ___________________________________________________________________
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I
ever have any change in my health, I will inform the doctors at the next appointment without fail.
_________________________________________________________________________ Date: _______________
Signature of patient, parent, or guardian
Dental History
Date of last visit to a dentist: _______________________ For what service? ___________________________
Has your child complained about dental problems? # Yes # No Is fluoride taken in any form?
Does your child brush teeth daily?
# Yes
# No
Any unhappy dental experiences?
Any habits – thumb-sucking, mouth breathing, sleeping with bottle, “sippy cup”, etc?
# Yes
# Yes # No
# Yes
# No
# No
Parent or Guardian Information
Mother/Guardian Information:
Name: _____________________________________________________________________________
# Male
# Female
# Married
# Single
# Other__________________________
Social Security #: _________________________ Birth Date: _________________________________
Phone (Home): ______________ (Work): ______________ Ext: __________ (Cell): ______________
Best time to call: ____________________________________
E-mail Address: _____________________________________________________________________
Address: ___________________________________________________________________________
Street
Apartment #
______________________________________________________________________________________________________
City
State
Zip Code
Employer Name: _________________________________ Occupation: _________________________
Address: ____________________________________________________________________________
Street
City
State
Zip Code
Father/Guardian Information:
Name: _______________________________________________________________________________
# Male
# Female
# Married
# Single
# Other____________________________
Social Security #: _________________________ Birth Date: __________________________________
Phone (Home): ______________ (Work): ______________ Ext: __________ (Cell): ________________
Best time to call: ____________________________________
E-mail Address: _______________________________________________________________________
Address: _____________________________________________________________________________
Street
Apartment #
__________________________________________________________________________________________________________
City
State
Zip Code
Employer Name: _________________________________ Occupation: ___________________________
Address: _____________________________________________________________________________
Street
City
State
Zip Code
Insurance Information
Primary
Name of Insured: ______________________________________________________________________
Last
First
MI
Insured’s Birth Date: ___________________ ID #: __________________ Group #: _________________
Patient’s relationship to insured:
# Child
# Other __________________________
Insurance Plan Name: _______________________________________ Phone #: ___________________
_____________________________________________________________________________________
Street
City
State
Zip Code
Secondary
Name of Insured: ______________________________________________________________________
Last
First
MI
Insured’s Birth Date: ___________________ ID #: __________________ Group #: _________________
Patient’s relationship to insured:
# Child
# Other __________________________
Insurance Plan Name: _______________________________________ Phone #: ___________________
_____________________________________________________________________________________
Street
City
State
Zip Code
Referral Information
Whom may we thank for referring you to our practice? # Friend # Dental Office
Internet Options: # Google # Bing # Insurance Web Site # Internet Other
# Yellow Pages
# School
Name of person or office referring you to our practice: _________________________________________________
Consent of Services
As a condition of your treatment by this office, financial arrangements must be made in advance. All emergency dental
services, or any dental services performed, must be paid for in full at the time services are performed.
This office will help prepare the patients insurance forms, submit them to your insurance company and assist in resolving
any unpaid claims. The patient is responsible for all charges if insurance does not pay. All estimates for dental work to be
performed are estimates only and do not commit your insurance company to payment.
A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60
days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date
of the patient examination.
Checks returned for insufficient funds are charged a $20 service fee and if not resolved within 10 days will be collected at
3 times the face value of the check. Parent or guardian is responsible for all costs incurred for collecting debts including
but not limited to attorney and collections agency fees.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this
form.
I hereby authorize the dentist to release all information necessary to secure payment of benefits. I authorize the use of this
signature on all insurance submissions and assign directly to Lucinda Ann Lewis DDS, PC all insurance benefits, if any,
otherwise payable to me for services rendered.
I authorize Dr. Lewis and the dental staff to perform all the necessary dental service for my minor child.
I have read the above conditions of treatment and payment and agree to their content.
____________________________________ Date: _______________ Relationship to Patient: _________________
Signature of parent or guardian
Please provide the name and phone number of two people not living with you who can contact you in event of an
emergency of if we are unable to reach you:
Name: ________________________ Phone # _____________________ Relationship: _______________________
Name: ________________________ Phone # _____________________ Relationship: _______________________
Payment Options:
Cash pay patients will receive a 10% discount on all services.
Payment plans are available through www.carecredit.com
# I wish to pay cash at the time of service.
# Please bill my insurance company and I will pay my co-payments at the time of service with cash, check, or credit card.
# Please keep my credit card number on file and bill the balance to my card after my insurance pays.
Credit card # _______________________________________________ Exp date: __________________________
NITROUS OXIDE INFORMED CONSENT
Although we do not use nitrous oxide for routine exams and cleanings, we would like to have your consent on file.
We use it as a helpful tool when we provide care such as fillings, extractions, nerve treatments, crowns, etc. There
is not a charge for Nitrous Oxide at our office. If you have any questions please ask Dr. Lewis or a staff member.
I HEREBY GIVE PERMISSION FOR DR. LEWIS AND STAFF TO PERFORM NITROUS OXIDE SEDATION.
I UNDERSTAND THAT THE ADMINISTRATION OF MEDICATION AND THE PERFORMANCE OF
CONSCIOUS SEDATION WITH NITROUS OXIDE CARRY CERTAIN COMMON HAZARDS, RISKS, AND
POTENTIAL UNPLEASANT SIDE EFFECTS, WHICH ARE INFREQUENT, BUT, NONETHELESS, OCCUR.
THEY INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:
•
•
•
•
•
•
EXCESSIVE PERSPIRATION: SWEATING DURING THE PROCEDURE, YOU MAY BECOME
SOMEWHAT FLOURISHED DURING ADMINISTRATION OF NITROUS OXIDE.
EXPECTORATIONS: REMOVAL OF SECRETIONS MAY BE DIFFICULT, BUT CAN BE
CONTROLLED BY THE USE OF SUCTION TIP.
BEHAVIORAL PROBLEMS: SOME PATIENTS WILL TALK EXCESSIVELY. YOU MAY BECOME
DIFFICULT TO TREAT BECAUSE YOU ARE SO TALKATIVE, OR EXPERIENCE VIVID DREAMS
ASSOCIATED WITH PHYSICAL MOVEMENT OF THE BODY.
SHIVERING: ALTHOUGH NOT COMMON, IT CAN BE QUITE UNCOMFORTABLE. SHIVERING
USUALLY DEVELOPS AT THE END OF THE SEDATIVE PROCEDURE WHEN THE NITROUS
OXIDE HAS BEEN TERMINATED.
NAUSEA AND VOMITING: THIS IS THE MOST FREQUENT OF THE SIDE EFFECTS OF NITROUS
OXIDE SEDATION BUT ITS FREQUENCY IS STILL QUITE LOW. IT IS IMPORTANT TO TELL
THE DOCTOR, HYGIENIST, OR ASSISTANT THAT YOU ARE EXPERIENCING SOME
DISCOMFORT. THE LEVEL CAN BE ADJUSTED TO ELIMINATE THE SIDE EFFECT.
DRIVING A MOTOR VEHICLE: YOU MAY NOT FEEL CAPABLE OF DRIVING AFTER NITROUS
OXIDE. IF THIS OCCURS, WE WILL KEEP YOU UNTIL YOU FEEL BETTER OR HAVE YOU
CALL A FRIEND OR A CAB TO ENSURE YOUR SAFETY.
I HAVE BEEN ADVISED OF THE ALTERNATIVE TREATMENT, THE BENEFITS AND RISKS WHICH
INCLUDE BUT ARE NOT LIMITED TO:
FEAR AND ANXIETY OF THE DENTAL EXPERIENCE AND/OR AVOIDANCE OF FUTURE DENTAL
APPOINTMENTS. THESE FEARS AND ANXIETIES IF NOT DIMINISHED BY THE USE OF NITROUS
OXIDE SEDATION MAY PRECIPITATE OTHER MEDICAL PROBLEMS INCLUDING FAINTING,
PALPITATIONS, AND OTHER HEART RELATED DISORDERS.
THE BENEFITS ONE CAN EXPECT FROM NITROUS OXIDE INCLUDE: HELP WITH ANXIETY AND
PAIN, GAGGING AND MEDICALLY COMPROMISED INDIVIDUAL.
I HEREBY CERTIFY THAT I UNDERSTAND THE AUTHORIZATION AND THE REASONS FOR THE
ABOVE NAMED SEDATIVE PROCEDURE AND ASSOCIATED RISKS. I AM AWARE THAT THE
PRACTICE OF DENTISTRY IS NOT EXACT SCIENCE. I HAD KNOWLEDGE THAT EVERY EFFORT
WILL BE MADE ON MY BEHALF FOR POSITIVE OUTCOME FROM SEDATION, BUT NO GUARANTEES
HAVE BEEN MADE TO ME AS TO THE RESULT OF THE PROCEDURE AUTHORIZED ABOVE.
PATIENT NAME:
DATE:
SIGNATURE OF PATIENT/GUARDIAN: _________________________________________________________