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Date _________________________________________________ _____________________________________________________ SS/HIC/Patient ID # _____________________________________ Relationship to Patient ___________________________________ Patient Name __________________________________________ Insurance Co.__________________________________________ _____________________________________________________ Group # ______________________________________________ Is patient covered by additional insurance? Address ______________________________________________ Subscriber’s Name______________________________________ E-mail ________________________________________________ Birthdate _________________ SS#_________________________ City __________________________________________________ State _______________________Zip ______________________ Relationship to Patient ___________________________________ Insurance Co.__________________________________________ Birthdate __________________________________ Group # ______________________________________________ ASSIGNMENTAND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with
______________________________________ and assign directly to Patient Employer/School _________________________________ Dr. ______________________________ all insurance benefits, if any,otherwise payable to me for services rendered. I understand that I am Occupation ____________________________________________ financially responsible for all charges whether or not paid by insurance.
I authorize the use of my signature on all insurance submissions.
Employer/School Address ________________________________ The above-named dentist may use my health care information and may _____________________________________________________ disclose such information to the above-named Insurance Company(ies) andtheir agents for the purpose of obtaining payment for services anddetermining insurance benefits or the benefits payable for related services.
Employer/School Phone(______) __________________________ This consent will end when my current treatment plan is completed or oneyear from the date signed below.
Spouse’s Name ________________________________________ ____________________________________________________________ Birthdate______________________________________________ Signature of Patient, Parent, Guardian or Personal Representative SS# _________________________________________________ ____________________________________________________________Please print name of Patient, Parent, Guardian or Personal Representative Spouse’s Employer _____________________________________ Whom may we thank for referring you? ______________________ PHONE NUMBERS
Phone (______)____________________ Work (______)____________________ Ext _____ Cell (______)____________________ Spouse’s Work (______) _________________________________ Best time and place to reach you______________________________ IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name ________________________________________________ Relationship ______________________________________________ Home Phone (______)___________________________________ Work Phone (______) ______________________________________ ACKNOWLEDGEMENT AND AUTHORITY
I consent to treatment as necessary or desirable to the care of the patient first named above, including but not restricted to whatever drugs,medicine, performance of operations and conduct of laboratory, x-ray, or other studies that may be used by the attending doctor, or his nurse orqualified designate. The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing orprocessing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of his/her staff responsible for any errors oromissions that I may have made in the completion of this form. I also acknowledge full responsibility for the payment of such services and agree topay for them, in full, AT THE TIME OF SERVICE. In the event of default of payment your account will be turned over to a collection agency. I agree topay all reasonable court costs, attorney fees and collection fees up to 50% of the delinquent balance. Date______________________Signature _______________________________________________________________ PATIENT, PARENT OR AGENT (MUST BE 18 YEARS OR OLDER) HEALTH HISTORY
Physician’s Name ________________________________________________ Date of last visit _________________________________ Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelviz, Didronel, Boniva. q Yes q NoHave you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Lonimin, Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). q Yes q NoPlace a mark on “yes” or “no” to indicate if you have had any of the following: Women:
Are you pregnant?
q Yes q No Due date ___________________________ MEDICATIONS
List any medications you are currently taking and the correlating q Barbiturates (Sleeping Pills)q Penicillin ______________________________________________________ ______________________________________________________ Pharmacy Name_________________________________________ Phone (______) _________________________________________ DENTAL HISTORY
Reason for today’s visit ___________________ Cigarette, pipe, or cigar smoking q Yes q No Former Dentist __________________________ City/State ______________________________ Date of last dental visit____________________ Date of last dental X-rays__________________ Food collection between the teethq Yes q No Place a mark on “yes” or “no” to indicate if you q Yes q No Sores or growths in your mouth q Yes q No q Yes q No How often do you floss?___________________ q Yes q No Loose teeth or broken fillings q Yes q No How often do you brush?__________________ Patient’s Signature _______________________________________________________ Doctor’s Signature _______________________________________________________

Source: http://www.sunwestdental.net/Portals/0/patientinfo_form2013.pdf


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