Patient Form

Patient's Name

Email

 

Office (For Office Use Only)

Age

 

Chart No (For Office Use Only)

Date

 

Dental History

Date of last dental visit

Date of last x-ray

 

Do you have an appliance(bridge,partial,dentures)?
 Yes No (If yes , Age of appliance):

 

What would you like to discuss with the dentist today ?

 

Medical History

(Required Information)

Physician’s Name:

Telephone #

 

Are you in good health? Yes No (If no, please explain):

 

•Have you had a blood transfusion?
 Yes No

 

•Have you taken weight loss medicine? (e.g. Fen-Phen)
 Yes No

 

•Do you Smoke?
 Yes No

•Use recreational drugs?
 Yes No

•Use chewing tobacco?
 Yes No

 

•Have you had prolonged bleeding?
 Yes No

 

•If yes, check all that apply:
 after an operation injury extractions

 

•Is there any family history of(check all that apply): Diabetes Heart murmur/problems Tumors

 

•Are you?(Women Only ) Pregnant Nursing Taking birth control pills

 

•Have you ever had any of the conditions listed below?  None
(Or Check all that apply)

 AIDS/HIV  Allergies  Anemia Angina Arthritis Artificial Joint Artificial Heart Valve Asthma Back Problem Bleeding Disorder

 Cancer  Chemical Dependency  Chemotherapy Cold Sores Diabetes Dizzy Spells Emphysema Emotional Disorder Epilepsy Fainting

 Fever Blisters  Heart Bypass  Heart Murmur  Heart Problem Heart Surgery Hepatitis High Blood Pressure HIV Positive Immunosuppressed Jaundice

 Kidney Disease  Liver Problems  Low Blood Pressure  Lung Disease Mitral Valve Prolapse Nervous/Mental Disorder Pacemaker Psychiatric Care  Radiation Therapy Rheumatic Fever

 Scarlett Fever  Sinus Trouble  Stroke Thyroid Problem  Tonsillitis Tuberculosis Ulcer

 

•Have you ever had any condition/problem not listed above?  Yes No (If yes, please explain):

 

•Medications: Please list all medications you are taking.

•Allergies: Please list allergies to any medications
 None (Or)

 
The above information is complete & accurate to the best of my knowledge. I will not hold my dentist or staff responsible for any omissions I have made in completing this form.
 

Patient signature/Responsible Party (if patient is a minor)

Date

 

Health history reviewed by

Date

 

Confidential Patient Information

(Please print clearly & be as thorough as possible.)

Patient Information

Name

Social Security

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

Email Address:

 

Responsible Party Information

(insurance carrier)

Name of insured

Social Security

 

Name of Insurance Co

Group #

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

 

Secondary Insurance Information

(complete this section if patient has dual coverage)

Name of insured

Social Security

 

Name of Insurance Co

Group #

 

Street:

Suite:

 

City/State:

Zip:

 

Date of Birth:

Home Phone:

 

Employer Name:

Work Phone:

 

Cell Phone:

Driver’s License #

 

Getting To Know You

Do you belong to the UCB campus?
 Yes NO
If yes, are you  Staff Student Other

 

UCB student ID (required)

 

How did you hear about us?

 

Emergency Contact List

Name

Phone Number

 

Insurance Patients Please Sign Below for Billing Purposes

I have reviewed the following treatment plan & fees. I agree to be responsible for all charges for dental services & materials not paid by my insurance plan, unless the treating dentist or dental elective has a contractual agreement with my plan prohibiting all or a portion of such charges to the extent permitted under applicable laws. I authorize release of any information relating to this claim. I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named entity.

**To Be Signed On Your First Office Visit**

Signature

Phone

 

Date