Avalon dental new patient forms

Patient Information Date________________ Name____________________________________________ Male/Female (Please circle) Birth Date____________ Social Security #__________________ Email_______________________ Home Address____________________________________________________________________ City_______________________________ State________________________Zip______________ Home # ____________________ Cel # ____________________ Work # _____________________ (Please Circle) Married Single Divorced Widowed Separated If student, name of school/college ___________________________ City___________ State______ Employer Name__________________________________ Occupation_______________________ Work Address____________________________________________________________________ City_______________________________ State________________________Zip______________ Whom may we thank for referring you? ______________________________________ Or how did you hear about our office? _______________________________________ Emergency Contact_____________________________________ Phone_____________________ Responsible Party (self, parent)____________________________ Phone ____________________ Is this person currently a patient in our office? (Please Circle) Yes No Primary Insurance Information Name of Insured_________________________________ Social Security # _________________ Insured Birth Date__________ Insurance ID #_______________ Group # __________________ Name of Insurance Company________________________ Phone Number__________________ Insurance Company Address___________________________________________ City____________________ State_______ Zip____________ Insured’s Employer Name__________________________________ Address___________________________________________ City____________________ State_______ Zip____________ Relationship to Insured_______________________ Secondary Insurance Information Name of Insured_________________________________ Social Security # _________________ Insured Birth Date__________ Insurance ID #_______________ Group # __________________ Name of Insurance Company________________________ Phone Number__________________ Insurance Company Address___________________________________________ City____________________ State_______ Zip____________ Insured’s Employer Name__________________________________ Address___________________________________________ City____________________ State_______ Zip____________ Relationship to Insured______________________ Cliff Broschinsky, D.D.S at Avalon Dental
2491 San Ramon Valley Blvd Ste. 4
San Ramon, CA 94583
Please list any medications you are taking: __________________________________ Have you been hospitalized for any surgical operation or serious il ness within the last 5 If yes please explain___________________ Others:_____________________________________ ___________________________________________ Cliff Broschinsky, D.D.S at Avalon Dental
2491 San Ramon Valley Blvd Ste. 4
San Ramon, CA 94583
Please take a few moments to answer the fol owing questions so we may provide better care: Do your gums bleed while brushing or flossing? Are your teeth sensitive to hot or cold liquids/foods? Are your teeth sensitive to sweet or sour liquids/foods? Do you have any sores or lumps in our near your mouth? Have you had any head, neck, or jaw surgeries? Do you bite your lips or cheeks frequently? Have you ever had difficult extractions in the past? Have you had any prolonged bleeding fol owing the extraction? Is there anything else you would like us Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Have you ever experienced any of the fol owing problems in your jaw? I certify that I have read and understand the information on the previous pages to the best of my knowledge. The questions have been answered accurately. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist. I authorize any examinations, x-rays, and treatments performed by Avalon Dental. I understand that my dental insurance carrier may pay less than the actual bil for services. I agree to be responsible for payment of al services rendered on my behalf or on behalf of my dependants. I understand that payment is due at the time services are rendered, unless other arrangements have been made with Avalon Dental. I understand that I must give a 24 hour cancellation or reschedule notice or a $50/$100 charge may be imposed depending on the length of the appointment. I, _________________________________________, acknowledge that I have received a Notice of Privacy Practices from the below named practice. Signature_____________________________________ Date___________________ Printed Name__________________________________ DDS Signature_________________________________ Date___________________ Cliff Broschinsky, D.D.S at Avalon Dental
2491 San Ramon Valley Blvd Ste. 4
San Ramon, CA 94583

Source: http://www.avalondental.co/San_Ramon_Dentist_Patient_Forms.pdf