Patient Contact Information

Patient Information (Complete ALL Sections!)

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Spouse/Guardian/Emergency Contact (Complete ALL Sections!)

Dental Coverage Information (Complete ALL Sections!)

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Dual Coverage Information (For patients who have two dental plans.)

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Appointment History (Complete ALL Sections!)

When were you last at the dentist?

When were your last dental x-rays?

Dental History (Please indicate, if applicable)

How did you hear about us?

Medical Insurance

Dental Coverage Information (Complete ALL Sections!)

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Dual Coverage I nformation

(For patients who have two dental plans.)

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Patient/Medical History

Medical History (Yes or No if you currently or have had any of the following conditions in the past.)

Heart Disease or Attack

Angina Pectoris 

High Blood Pressure  

Heart Murmur  

Rheumatic Fever

Congenital Heart Lesions

Mitral Valve Prolapse  

Heart Pacemaker

Heart Surgery

Artificial Joint (Hip, Knee)



Kidney Disease

Stomach Ulcers

Hepatitis A (Infectious)

Hepatitis B (Serum)

AIDS/HIV Positive

Liver Disease

Blood Transfusion

Yellow Jaundice

Drug Addiction





Venereal Disease  



Radiation Therapy 




Sinus Pain/Drainage 


Thyroid Disease  


Cortisone Treatment 

Psychiatric Treatments 

Sickle Cell Disease  

Sleep Apnea

Do you have any disease or problem not listed above?

If so please explain

Taken alendronate (Fosamax®), or risedronate (Actonel®)?

Being treated or treated in the past with intravenous bisphosphonates (Aredia®,Fosamax®,or Zometa®) for bone pain, hypercalcemia, or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Latex Allergy

Do you smoke?

Ready to quit?

Currently under the care of a physician?

Are you pregnant?

Are you allergic to any medications

Dental checklist

It is very important to us that we take care of your specific needs.
Please check either YES or NO to the things that pertain to you.

I have not been to a dentist in a long time and I’m worried about what you will tell me about my oral hygiene.  

I am embarrassed with the way my teeth look. 

I would like to see pictures and videos that will help me understand my dental problems 

I have had a bad dental experience and have a lot of fear which has kept me from getting the dental care I  need.  

I am interested in achieving and maintaining good oral health. 

I greatly fear going to the dentist.  

I am interested in having a dental cleaning today. 

I have a toothache and that is my biggest concern today.  

I would like to replace my silver fillings with tooth colored fillings. 

I am interested in a smile makeover. 

I want to know more about teeth whitening. 

I want to know more about straightening my teeth. 

I snore or someone has told me I snore. 

I currently wear a CPAP, but find it uncomfortable and want an alternative device. 

I suffer from migraines and want to know how the dentist can give me migraine relief.  

I am interested in learning about financing options so that I may be able to spread my payments out over time. 

I do not have dental insurance and would like to know more about the Quality Dental Plan that Dr. Fryer’s office offers..

Consent for Treatment

I hereby certify that all above patient, medical, and dental information is correct and authorize Dr. Fryer and staff to take x-rays, study  models, photographs, or any other diagnostic aids seemed appropriate by Dr. Fryer to make a thorough diagnosis of my dental needs. I  authorize Dr. Fryer to perform any and all kinds of treatment, medication, and therapy that may be indicated. If any conditions are  discovered in the course of treatment which, in the opinion of the doctor require additional procedures or procedures different than those  described, I also authorize the performance of these procedures. I also understand that the use of anesthetic agents embodies a certain  risk. 

I understand that my dental insurance is a contract between me and the insurance carrier and NOT between the Doctor and that I am still  fully responsible for all dental needs. These fees are due and payable at the time services are rendered unless prior financial arrangements  have been made. I also assign all insurance payments to the Doctor. Any payments received by the Doctor from my insurance coverage  will be credited to my account, or refunded to me if I have paid the dental fees incurred.

I hereby state that I have read and understand this consent, and that all questions about the procedures have been answered to my  satisfaction.
I consent for Kevin W. Fryer DDS Inc to send dental claims on my behalf (if applicable) and that the claim payment be sent to this office. 

Warranty/Missed Reservation Policy

At Kevin W. Fryer DDS Inc., we pride ourselves on providing optimal dental health to all of our patients and their families.   We stand behind our work, which is why we are happy to provide to you a 5 year warranty on a variety of services,  something few other offices offer. 

Our Part 
If our sealants, composite fillings, veneers, inlays, onlays, bridges, or crowns need replacement within 5 years, and the  tooth is still restorable, we will replace the restoration of the same type, at no cost to you! All that we ask is you do your  part in maintaining optimal dental health. 

Your Part  
If you brush and floss in the morning and in the evening daily, come to our office for your regular 6-month check-up, and  complete all the recommended treatment at our office, you can prevent most or all disease. You must been seen at least  twice a year (at our office) for a check-up to consider our warranty in effect.  

Missed Dental Reservation Policy 

At Kevin W. Fryer DDS Inc, we pride ourselves on being prepared and ready for our patients. We kindly ask the same from  you! If you ever need to reschedule a dental reservation with our office, there are many ways to reach our office-you can  call us at 440-585-4200, email us at, text us at 440-646-1004, or stop in. 

If you are unable to make an appointment, we ask for a 48 hour notice to avoid a $50 fee. 

Authorization and Consent to Use and Disclose Medical Information  

The Medical Privacy Notice of Kevin W. Fryer DDS Inc provides information about how we may use and disclose  confidential medical information about you. You have the right to read our Notice before signing this consent. The terms of   our Notice may change from time to time. If changed, we would inform you at your next visit.  

By signing this Authorization, you agree to let us use and disclose confidential medical information about you for  treatment, payment, and dental office operations. This includes information about your dental health and medical health.  You are also consenting to the release of health information about you to your insurer, third party, or other agents needed  to get payment for your treatment. 


Signature of Patient/Guardian
I have read the above warranty.
I have read the above policy.
I have read the above policy.

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