59371_gentledental_adultform.indd

Gentle Dental Care
Thomas D. Deppe, D.D.S. • Jarom L. John, D.D.S.
Mark T. McDonald, D.D.S. • Bryan R. Medaris, D.D.S.
The benefits of a happy, healthy smile are immeasurable. Our goal is to help you reach and main-
tain maximum oral health. Please fill out these forms completely. The better we communicate, the
better we can care for you.
Primary Dental Insurance
Insurance Co. Name: _______________________________________ Name: __________________________________________________
Insurance Co. Address: _____________________________________ I prefer to be called: _________________________ ❑ Male ❑ Female Insurance Co. Phone #: _____________________________________ Birthdate: ____/____/____ Age:____Social Security #: ____________ Group # (Plan Local or Policy #): _____________________________ Home Address: ___________________________________________ Insured’s Name: _______________________ Relation:_____________ City, State, Zip: ___________________________________________ Insured’s Birthday: _________________ Insured’s SS#:____________ Single ❑ Married ❑ Divorced ❑ Widowed ❑ Separated Insured’s Employer: ________________________________________ Home #: ______________________ Pager/Cell#:_________________ Secondary Dental Insurance
WK#: _____________________ Ext._________DL#:______________ Insurance Co. Name: _______________________________________ Employer: _______________________________________________
Insurance Co. Address: _____________________________________ Employer’s Address: _______________________________________ Insurance Co. Phone #: _____________________________________ How long there?__________ Occupation:_______________________ Group # (Plan Local or Policy #): _____________________________ Where & when are the best times to reach you? _________________ Insured’s Name: _______________________ Relation:_____________ Who may we Thank for referring you? _________________________ Insured’s Birthday: _________________ Insured’s SS#:____________ Other family members seen by us: ____________________________ Insured’s Employer: ________________________________________ Previous/Present Dentist: ___________________________________ Last Visit Date:____________________________________________ In the event of an emergency, is their someone who lives near you that we should contact? Their Name: ______________________ Relation:_________________ Their Name: ______________________________________________ WK#: _______________________________HM#:________________ Employer: ________________________________________________ WK#: _______________________ Ext.______SS#:_______________ Birthdate: _______________________ DL#:_____________________ Do you have a personal physician? ❑ No ❑ Yes
Person Responsible for Account: ___________________________
Physician’s Name: _________________________________________ WK#: __________________ Ext.______ HM#:___________________ Phone#: _______________________Date of last visit:_____________ Billing Address: ___________________________________________ Relationship: ____________________ SS#:_____________________ Employer: _______________________ DL#:_____________________ Your current physical health is: ❑ Good ❑ Fair ❑ Poor
Why have you come to the dentist today? ____________________
Are you currently under the care of a physician? ❑ No ❑ Yes ________________________________________________________ Please Explain: ___________________________________________ ________________________________________________________ Are you taking any prescription/over-the-counter drugs? ❑ No ❑ Yes Are you currently in pain? ❑ No ❑ Yes Please list each one _______________________________________ Have you ever had a serious/difficult problem associated with any pre- For Women Are you taking birth control pills? ❑ No ❑ Yes
Are you pregnant? ❑ No ❑ Yes Week # ___________________ Do you now or have you ever experienced pain/discomfort in you
jaw joint (TMJ/TMD)? ❑ No ❑ Yes
Have you ever had any of the following
Your current dental health is ❑ Good ❑ Fair ❑ Poor diseases or medical problems?
Do you like the appearance of you smile? ❑ No ❑ Yes If you could change anything about it, what would you change? ________________________________________________________ How many times a day do you brush?_____ a week do you floss?____ I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information 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 the dental Y N Severe/Freq. Headaches Y N Hepatitis/Liver Problems staff to perform any necessary dental services with my informed con- sent that I may need during diagnosis and treatment. Please list any serious medical condition(s) that you have ever had:
________________________________________________________ ________________________________________________________ ________________________________________________________ Payment is due in full at the time of treatment unless prior ________________________________________________________ Do you use chewing tobacco? Y N Currently____ How Long____ Thank you for filling out this form completely. Have you ever smoked? Y N Currently_____ How Long_____ Packs a Day_____ It will enable us to help you more effectively. If you Are you allergic to any of the following drugs?
have any questions at any time, please ask us. Please list any other drugs that you are allergic to: Our office is committed to meeting or exceeding the standards of ________________________________________________________ infection control mandated by OSHA, the CDC and the ADA.
I authorize the dental staff to perform the dental services for me where appropriate, including, but not limited to; full mouth exam radiographs, (x-rays), cleaning, fluoride treatment and sealants on molars.
Patient Signature and/or Parent/Guardian when Patient is a minor How did you hear about our office?
________ Friend Referral_______________________ ________ Other_______________________________

Source: http://www.gentledental.biz/docs/forms/adult_health_history.pdf