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 @ _______________%