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    Welcome Rev2

    Uploaded by

    Adam C. Price
    This document contains a dental patient information and medical history form. It requests information such as the patient's name, birthdate, address, phone numbers, insurance details, employer information, and emergency contact. The medical history section lists various medical conditions and asks the patient to check any they have. It also requests current medications and reasons for dental visit. The form notes that the information provided is complete and correct, and authorizes the dental office to release information to and obtain payment from the patient's insurance companies. It also states the patient is financially responsible for treatment costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Welcome Rev2

    Uploaded by

    Adam C. Price
    29 views2 pages
    This document contains a dental patient information and medical history form. It requests information such as the patient's name, birthdate, address, phone numbers, insurance details, employer information, and emergency contact. The medical history section lists various medical conditions and asks the patient to check any they have. It also requests current medications and reasons for dental visit. The form notes that the information provided is complete and correct, and authorizes the dental office to release information to and obtain payment from the patient's insurance companies. It also states the patient is financially responsible for treatment costs.

    Copyright

    © © All Rights Reserved

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    This document contains a dental patient information and medical history form. It requests information such as the patient's name, birthdate, address, phone numbers, insurance details, employer information, and emergency contact. The medical history section lists various medical conditions and asks the patient to check any they have. It also requests current medications and reasons for dental visit. The form notes that the information provided is complete and correct, and authorizes the dental office to release information to and obtain payment from the patient's insurance companies. It also states the patient is financially responsible for treatment costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views2 pages

    Welcome Rev2

    Uploaded by

    Adam C. Price
    This document contains a dental patient information and medical history form. It requests information such as the patient's name, birthdate, address, phone numbers, insurance details, employer information, and emergency contact. The medical history section lists various medical conditions and asks the patient to check any they have. It also requests current medications and reasons for dental visit. The form notes that the information provided is complete and correct, and authorizes the dental office to release information to and obtain payment from the patient's insurance companies. It also states the patient is financially responsible for treatment costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Date:

    Name Birthdate
    Email
    Address City State Zip
    Sex M F Widowed Single
    Divorced
    Address City State Zip
    Employer
    Phone
    Name of person
    Responsible for this account
    Address
    Birthdate
    Yes No Email
    SS #
    Address City State Zip
    Address City State Zip
    How much is your deductible?
    Name of Insured
    Birthdate SS #
    Address City State Zip
    Address City State Zip
    How much is your deductible?
    Thank you for trusting us with your dental care.
    We Promise to do our best to provide you with
    the finest care available. If you have any
    questions, please do not hesitate to call us.
    Employer/School
    PATIENT INFORMATION
    Minor
    Partnered
    Home Phone ( )
    RESPONSIBLE PARTY
    INSURANCE INFORMATION
    Relation to Patient
    Home Phone
    Spouse or Parent name Work Phone ( )
    Whom may we thanks for referring you?
    Person to contact in case of an emergency ( )
    Employer Work Phone ( )
    Current Patient in our office?
    ( )
    Driver's License # Cell Phone ( )
    Employer Work Phone ( )
    Relation to Patient
    Date Employed
    Group Number
    How much have you used? Max Benefit?
    ( )
    ADDITIONAL INSURANCE
    Relation to Patient
    Date Employed
    Patient #
    Insurance Company
    Insurance Company
    Name of Insured
    Birthdate
    ( ) Employer/School Phone
    Cell Phone ( )
    Group Number
    How much have you used? Max Benefit?
    Employer Work Phone
    Married
    Separated
    Address
    Yes No
    Yes No Nursing Yes No
    Arthritis, Rheumatism Liver Disease
    Artificial Heart Halves Pacemaker
    Artificial Joints, Pins, etc Radiation Tyreatments
    Asthma Respiratory Disease
    Back Problems Shortness of Breath
    Bleeding Abnormally Skin Rash
    `
    Blood Disease Stroke
    Cancer Thyroid Problems
    Chemical Dependency Tobacco Habit
    Chemotherapy Tonsillitis
    Circulatory Problems Tuberculosis
    Congenital Heart Problems Ulcer
    List medications you are currently taking and the correlating diagnosis: Allergies
    DENTAL HISTORY
    MEDICAL HISTORY
    Bad Breath Grinding teeth
    Bleeding gums
    Reason for today's visit Date of last dental care
    Former Dentist Date of last dental X-rays
    Check if you have had problems with any of the following:
    Check if you have or have had any of the following:
    Sensitivity when biting
    (women only) Are you Pregnant?
    Acid Reflux Disease Jaw Pain
    Physician's name Date of last visit?
    Have you had any serious illness or operations?
    If yes, please describe
    Clicking or popping jaw
    Food collection between teeth
    Loose teeth or broken fillings
    Periodontal treatment
    Sores or growths in your mouth
    Heart Problems
    Hemophilla
    Hepatitis
    Glaucoma
    Headaches
    Heart Murmur
    Cough, Persistent
    Diabetes
    Epilepsy
    Fainting
    Anemia
    Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient
    Date
    Sensitivity to hot
    Sensitivity to cold
    Sensitivity to sweets
    Dr. Tristan Galloway may use my health care information and may disclose such information to the above-named insurance compan(ies) and their agents for the purpose of
    obtaining payment for services and determining insurance benefits or the benefits payable for related services.
    Signature of Patient, Parent, Guardian or Personal Representative
    How often do you floss? How often do you brush?
    To the best of my knowledge, the above information is complete and correct. I understand that is is my responsibility to inform my doctor if I, or my minor child, ever have a
    change in health.
    I certift that I, and/or my dependant(s), have insurance coverage with _________________________________________________ and assign directly to Dr. Tristan Galloway
    Name of Insurance compan(ies)
    all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I
    authorize the use of my signature on all insurance submissions.
    Kidney Disease
    Payment is due in full at time of treatment unless prior arrangements have been approved.
    Illegal Drug use
    AUTHORIZATION AND RELEASE
    Hernia Repair
    High Blood Pressure
    HIV/AIDS
    Updated Date
    Updated Date
    Changes noted on Form: Patient Initials
    Changes noted on Form: Patient Initials
    No Change
    No Change

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