WELCOME! Name:____________________________________________ First Middle In. Last Address:__________________________________________ __________________________________________ City: ____________________ State:______ Zip:________ Do you have a preferred name? _________________________ How do you prefer to be reached? (Please circle) Email Cell phone Home phone Work phone Date of Birth:____/____/____ Home phone:____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Male/Female Social Security #______-_____-______ Email address _______________________________ Occupation:_________________________________ Marital status (please circle) Single Married Divorced Widowed Separated Employer:___________________________________________ How did you hear about us? ____________________ Do you have any hobbies? ______________________________ In case of an emergency contact: Name:______________________ Phone:_________________ Primary Care Doctor:______________________________________ Phone:_________________ Do you have primary dental coverage? Yes/No Insurance company name:_________________________ Phone # __________________ Policy holder/subscriber ID# _________________ Policy holder name:_____________________ Policy holder date of birth:____/____/____ Do you have a secondary dental policy? Yes/No Insurance company name:_________________________ Phone # __________________ Policy holder/subscriber ID# _________________ Policy holder name:_____________________ Policy holder date of birth:____/____/____ I authorize payment directly to the dentist of any group insurance benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by this authorization. I authorize release of any information relating to/necessary for the process of any dental claim or claims. ______________________________________ (Guardian/Patient) Signature We pride ourselves on giving you undivided attention during your visit with us. To do this we reserve your appointment time just for you. We value your time, and you can expect us to be on time for your appointment. We expect and appreciate the same courtesy. Occasionally emergencies can interrupt our schedule, and we do our best to call you if we know in advance. If it is unavoidable for you to reschedule your appointment, we require two business days’ notice so that another patient has an opportunity to utilize the time reserved for you. In absence of this required two day notice you will be charged a $30.00 broken appointment fee. ____/_____/____ Date Our front office team has extensive knowledge and experience with dental benefit plans, and is passionate about gaining the highest possible benefit from your plan for you. We cannot, however, guarantee payment on behalf of your benefit company. While we will do everything possible to gain payment on your behalf, it is important that you know there is never a guarantee of payment from an insurance company until they issue payment, and you are ultimately responsible for any balance that may remain after insurance, including reimbursement to us any collection agency fees, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts. I have read and agree to the above information, and have answered the above questions accurately. ______________________________________ (Guardian/Patient) Signature ____/_____/____ Date DENTAL/MEDICAL HISTORY What is reason for your appointment today? ___________________________________________________________________ Do you require antibiotics before dental treatment? Y/N Do you now or have you ever experienced pain or discomfort in your jaw? (TMJ/TMD) Y/N Are you allergic to any of the following? Are you taking any of the following? Y / N Aspirin Y / N Barbiturates Y / N Codeine Y / N Dental Anesthetics Y / N Erythromycin Y / N Jewelry/Metals Y / N Latex Y / N Penicillin Y / N Sedatives Y / N Sulfa Drugs Y / N Tetracycline Y / N Other: _______________________________________________ _______________________________________________ Date of last physician visit: ____/____/____ Are you currently under the care of a physician? Y / N Please explain:___________________________________ Are you taking birth control pills? Y / N Pregnant? Y / N Nursing? Y /N Y / N Acetaminophen Y / N Antibiotics Y / N Antihistamines Y / N Aspirin Y / N Blood Thinners Y / N Blood Pressure Medication Y / N Cold Remedies Y / N Digitalis/Heart Medication Y / N Insulin/Diabetes Drugs Y / N Nitroglycerine Y / N Recreational Drugs Y / N Steroids/Cortisone Y / N Thyroid Medicine Y / N Tranquilizers Do you smoke or use tobacco in any form? Y / N Are you taking any drugs not listed above? Y / N Do you or have you experienced the following? Y / N Abnormal Bleeding Y / N Alcohol Abuse Y / N Anemia Y / N Arthritis Y / N Artificial Bones/Joints Y / N Artificial Valves Y / N Asthma Y / N Blood Transfusion Y / N Cancer Y / N Chemotherapy Y / N Chicken Pox Y / N Colitis Y / N Congenital Heart Defect Y / N Daytime Sleepiness Y / N Diabetes Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Difficulty Breathing Drug Abuse Emphysema Epilepsy Fainting Spells Fever Blisters Glaucoma Hay Fever Headaches Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Herpes High Blood Pressure HIV+ or AIDS Hospitalization(s) Kidney Problems Liver Disease Low Blood Pressure Lupus Mitral Valve Prolapse Morning Headaches Pacemaker Persistent Cough Psychiatric Problems Radiation Treatment Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Rheumatic Fever Scarlet Fever Seizures Shingles Sickle Cell Anemia Sinus Problems Sleep Apnea Snoring Steroid Therapy Stroke Thyroid Problems Tonsillitis Tuberculosis (TB) Ulcers Venereal Disease Have you ever been prescribed or are you currently wearing a C-PAP machine? Y / N Do you have any other health conditions or allergies not listed? Y / N ______________________________________________ Authorization I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize Dr. Ely to perform the necessary dental services I may need. ________________________________________ (Guardian/Patient) Signature ____/____/____ Date