Today’s Date:

Today’s Date:
Date of Birth
Sex
Male
Female
Patient’s Name
Email:
Spouse’s or Parent’s Name (If patient is a minor)
/
Cell Phone:
(
)
Employer:
Home Phone
(
)
Address(Street & Apartment#)
Address(City,State & Zip)
Social Security Number:
/
Patient Is:
Minor
Married
Single
Student
Full Time
Employed
Part Time
Other
Emergency Contact:
Widowed
Emergency Contact Phone:
(
)
Employer Phone:
(
)
Whom May We Thank for Referring
You?
What is your main concern for Dr.?_________________________________________________________________
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.
Are you under a physician’s care now? Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Are you taking any medication, pills,or drugs? Have you ever taken Fosamax, Boniva,Actenol or any other
medication containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you
Pregnant/trying to get pregnant?
Taking oral contraceptives? Yes
Yes
No
Yes Yes Yes Yes No No No No If yes, please explain:_________________________________________________________
If yes, please explain:_________________________________________________________
If yes, please explain:_________________________________________________________
If yes, please explain:_________________________________________________________
Yes No
If yes, please explain:_________________________________________________________
No No No Yes Yes Yes If yes, please explain:_________________________________________________________
If yes, please explain:_________________________________________________________
If yes, please explain:_________________________________________________________
No
# of weeks______________
Nursing? Yes
No
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
Other If yes, please explain:__________________________________________________________________________________________________________________
Do you have , or have you had, any of the following?
AIDS/HIV Positive Yes No Cortisone Medicine Alzheimer’s Disease Yes No Diabetes Anaphlaxis Yes No Drug Addiction Anemia Yes No Easily Winded Angina Yes No Emphysema Arthritis/Gout Yes No Epilepsy or Seizures Artificial Heart Valve Yes No Excessive Bleeding Artificial Joint Yes No Excessive Thirst Asthma Yes No Fainting Spells/Dizziness Blood Disease Yes No Frequent Cough Blood Thinners Yes No Frequent Diarrhea Blood Transfusion Yes No Frequent Headaches Breathing Problem Yes No Genital Herpes Bruise Easily Yes No Glaucoma Cancer Yes No Hay Fever Chemotherapy Yes No Heart Attack/Failure Chest Pains Yes No Heart Murmur Cold Sores/Fever Blisters Yes No Heart Pacemaker Congenital Heart Disorder Yes No Heart Trouble/Disease Convulsions Yes No Hemophilia Have you ever had any serious illness not listed above?
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/ Intestinal Disease
Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Veneral Disease Yellow Jaundice Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
_________________________________________________________________________________________
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 of any changes in medical status.
SIGNATURE OF PATIENT, PARENT or GUARDIAN _______________________________________________________________________ DATE _______________________________
Responsible Party Information:
( This is the account guarantor and this person MUST sign below)
Name_____________________________________________
Relation to Patient__________________________________
Address____________________________________________
City ____________________ State _________ Zip_________
Birth Date ____________/ ______________/_____________
Social Security #____________________________________
Dental Insurance Information
( Please complete information even if you’ve presented a card to us.
Name of Policy Holder______________________________
Relation to Patient__________________________________
Policy Holder’s Birth Date _______/ _________/_________
SS#/ Identification #:_ ______________________________
Group or Policy #___________________________________
Sex Male Female
Policy Holder’s Employer____________________________
Home Phone (
)_____________________________
Cell Phone (
)_______________________________
Insurance Company________________________________
Employer___________________________________________
Phone (
)__________________________________
Employer Phone (
)__________________________
Do you have secondary dental insurance coverage? ______________ If yes, please present your card to us.
Financial Agreement:
Payment Options:
3 Dental Savings Plan
3 I understand payment is due at the time of service. If I have
dental insurance, a claim will be submitted.
3 Cash, Check or Credit Card at time of service.
3 I understand all balances over 90 days are subject to a 1.5%
per month billing charge. I agree to be responsible for all
charges.
3 Extended payment plan( Care Credit)
3 Payment in full prior to treatment:5% discount(if over 1,000.00)
I hereby authorize and direct The John Fornetti Dental Center as assisted by other dentists and auxilliaries,
to perform any necessary dental treatment.
All patients under the age of 18 must have a parent or legal guardian present for all scheduled appointments.
____________________________________________________ Patient/Guardian Signature( Account Guarantor) ________________________________________
Date
FOR OFFICE USE ONLY
Patient:
Patient’s DOB:
Ins.Policy Subscriber: DOB: SS# or Insurance ID:
Coverage
SINGLE
SPOUSE
FAMILY
Group #:
Employers Name:
Ins.Co. Name: Ins. Co. Phone #:
Effective Date:
Maximum per Benefit Period: Deductible: _____________ =Individual______________ =Family
Calendar Year
or
Plan Year ______________ to ___________
Preventative %:
Deductible on Preventative:
2 EX/PX a year or 1 every 6 months: Sealant Coverage:
Fluoride:
Date Verified:
By whom:
Ins. Co . Address:
Benefits used this year:
FMX/Pano: BW: X-ray Hx:
Requested X-rays?:
Basic %: Waiting period on basic:
Perio/SRP: BASIC MAJOR
PMT: PREV BASIC............................MAJOR .............................. Frequency:
Posterior Comps: AMALGAM COMPS
___%
Endo: BASIC MAJOR
Oral Surgery: BASIC MAJOR
Sedation: BASIC MAJOR
Major%: Crown pays:
PREP
SEAT Replacement: Implant Coverage: Ortho Coverage: Age Limit
______
Notes on Ortho Payment Disbursement:
Max
Waiting period on major:
Occlusal Guards/NTI:
Coordinate Benefits:
Missing Tooth Clause:
_____ Deduct _____________ , then @ _______________%