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Patient Information

Tell us a bit about you so we can prepare for your first visit.

Today's date

Patient's name

Sex

Male

Female

Date of birth

Age

If minor, person responsible for account

Home phone

Mobile phone

Email

Home address

City

State

Zip

Social security number

Driver license number

Employer name

Occupation

Business address

Business phone

How did you hear about our office? (Google, Yelp, insurance website, referral, etc)

Insurance Information

Patient is covered by

Dental Insurance

No Insurance

Name of the person the insurance is under

Date of birth

Employer name

Social security number

Insurance company name

Group name

Group or policy number

Is the patient covered by a secondary insurance?

Yes

No

If yes, please provide the secondary insurance information

Planned method of payment

Cash

Credit card

Dental History

Does the patient have any dental pain? If yes, please describe

Name of your past dentist

When was your last checkup or cleaning?

What would you like to discuss today? E.g., checkup, cosmetic concerns, etc.

Does dental treatment make you nervous?

No

A little

Very

Medical History

Name of your family physician

Phone

Is patient in good health?

Emergency contact

Phone

Please list all medications or herbs you are currently taking

Have you ever taken Phen Fen, Redux, or Fosamax?

Yes

No

Are you allergic or sensitive to any of the following?

Which?

Please check any that you have had or currently have

Answer Yes or No for each condition.

High blood pressure

Yes No

Pacemaker

Yes No

Prosthetic heart valve

Yes No

Heart attack or defects

Yes No

Stroke arteries hardening

Yes No

Neurological disorders

Yes No

Kidney bladder disease

Yes No

Tumor cancer

Yes No

Radiation or chemotherapy

Yes No

Asthma

Yes No

Dry mouth

Yes No

Dizziness

Yes No

Chest pain

Yes No

Anemia

Yes No

Arthritis

Yes No

Hepatitis

Yes No

Diabetes

Yes No

Seizures

Yes No

Headaches

Yes No

Shortness of breath

Yes No

Sinus problems

Yes No

Eye disease

Yes No

Lung disease

Yes No

Heart murmurs

Yes No

Heart disease

Yes No

Liver problems

Yes No

Tuberculosis

Yes No

Persistent cough

Yes No

Bleeding or bruising

Yes No

High cholesterol

Yes No

Stomach problems

Yes No

Thyroid disease

Yes No

Rheumatic fever

Yes No

Artificial joint

Yes No

Psychiatric care

Yes No

AIDS / HIV

Yes No

Herpes

Yes No

Do you have or have had medical problems NOT listed here?

Yes

No

Do you smoke?

Yes

No

Past use

If yes, how much?

Recreational drugs

Yes

No

Past use

Alcohol

Yes

No

Past use

For women

Pregnant

Nursing

On birth control pills

Postmenopausal

I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

I authorize Sawtelle Smiles Dental and its affiliates, agents, service providers, or assignees ("SSD") to examine and provide dental treatment.

I assume full responsibility for any balance due. I authorize my insurance company to pay by check, debit card, or any other payment method made out to SSD or its associates.

I authorize SSD to release any medical or incidental information that may be necessary for medical care or payment. I understand and agree that it is my responsibility to know all rules and restrictions of my insurance policy.

I understand and agree to SSD's policy to share Protected Health Information ("PHI") with labs, x-ray labs, consulting physicians, and hospitals, to call the pharmacy of my choice regarding my prescriptions, and to exchange the necessary PHI for each transaction.

Date

Relationship to patient

Consents, Authorizations, and Acknowledgements

Communications. By providing the number of a phone or other wireless device and/or an email address now or in the future, I expressly consent and agree that Sawtelle Smiles Dental and its affiliates, agents, service providers, or assignees (collectively, "SSD") may call me using an automatic telephone dialing system, leave me voice messages (including prerecorded or artificial voice messages), or send me a text message, email, or other electronic or written communications for any purpose related to treatment, scheduling, insurance, payment, my account, birthdays, transactional, or other informational purposes ("Communications"). I also agree that SSD may include my personal information in such Communications. I acknowledge that standard phone charges by my wireless provider may apply as determined by my wireless provider.

Dental Materials Fact Sheet and Notice of Privacy Practices. By signing this document, I acknowledge that I have received a copy of the Dental Materials Fact Sheet and the Notice of Privacy Practices.

Appointments. SSD is a patient-centered practice and makes every reasonable effort to ensure that your dental experience is pleasant. To achieve this, we reserve specific appointment times for each patient. When a patient misses a scheduled appointment, that time is lost to others who could have been treated. Therefore, I understand that I must provide at least 48 business hours' notice (excluding weekends) to cancel or reschedule an appointment. I understand that failure to do so may result in a broken appointment fee. For example, if your appointment is on Monday at 3PM, you must notify us by or before the preceding Wednesday at 3PM.

Financial Terms and Conditions. I understand that all financial arrangements must be made before any treatment begins. I understand that services furnished to me or persons for whom I am responsible are charged directly to me and that I am personally responsible for payment. SSD requires payment at time of initiation of service.

If I have insurance, I understand that SSD will assist by preparing and submitting insurance claims on my behalf. However, SSD cannot render services under the assumption that insurance benefits will fully cover the charges. I acknowledge that I am ultimately responsible for payment and agree to pay any outstanding balance at the time services are rendered or upon receipt of the explanation of benefits, unless prior arrangements have been made.

Date

Print name

Relationship to Patient

E-Signature

Please sign electronically below.