Patient Information Date of Birth (required) Sex (required) MFPrefer not to answer Address Information (required): Marital Status (required) MarriedSingleMinorOther How did you find out about us? (required) ---I am a previous patientBeaconDoctorFacebookInsurance CompanyPatient ReferralPhonebookOnline SearchRadioOther Phone Numbers IN CASE OF EMERGENCY, CONTACT Dental Information Date of last dental visit:Date of last X-ray:Select "yes" or "no" to indicate if you have had any of the following: Bad breath YesNo Bleeding gums YesNo Blisters on lips or mouth YesNo Burning sensation on tongue YesNo Chew on one side of mouth YesNo Cigarette, pipe, or cigar smoking YesNo Clicking or popping jaw YesNo Dry mouth YesNo Fingernail biting YesNo Food between the teeth YesNo Foreign objects YesNo Grinding teeth YesNo Gums swollen or tender YesNo Jaw pain or tiredness YesNo Lip or cheek biting YesNo Loose teeth or broken fillings YesNo Mouth breathing YesNo Mouth pain, brushing YesNo Orthodontic treatment YesNo Pain around ear YesNo Periodontal treatment YesNo Sensitivity to cold YesNo Sensitivity to heat YesNo Sensitivity to sweets YesNo Sensitivity when biting YesNo Sores or growths in your mouth YesNo Health History Date of Last Visit: Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. YesNo Are you required to pre-medicate before dental treatment? YesNo Select "yes" or "no" to indicate if you have had any of the following: AIDS/HIV YesNo Anemia YesNo Arthritis, Rheumatism YesNo Artificial Heart Valves YesNo Artificial Joints YesNo Asthma YesNo Back Problems YesNo Bleeding abnormally, withextractions or surgery YesNo Blood Disease YesNo Cancer YesNo Chemical Dependency YesNo Chemotherapy YesNo Circulatory Problems YesNo Congenital Heart Lesions YesNo Cortisone Treatments YesNo Cough, persistent or bloody YesNo Diabetes YesNo Emphysema YesNo Do you wear contact lenses? YesNo Epilepsy YesNo Fainting or dizziness YesNo Glaucoma YesNo Headaches YesNo Heart Murmur YesNo Heart Problems YesNo Hepatitis YesNo Herpes YesNo High Blood Pressure YesNo Jaundice YesNo Jaw Pain YesNo Kidney Disease YesNo Liver Disease YesNo Low Blood Pressure YesNo Mitral Valve Prolapse YesNo Nervous Problems YesNo Pacemaker YesNo Psychiatric Care YesNo Radiation Treatment YesNo Respiratory Disease YesNo Rheumatic Fever YesNo Scarlet Fever YesNo Shortness of Breath YesNo Sinus Trouble YesNo Skin Rash YesNo Special Diet YesNo Stroke YesNo Swollen Feet or Ankles YesNo Swollen Neck Glands YesNo Thyroid Problems YesNo Tonsillitis YesNo Tuberculosis YesNo Tumor or growth onhead or neck YesNo Ulcer YesNo Venereal Disease YesNo Weight Loss, unexplained YesNo Women: Are you pregnant (required)? YesNo Due Date: Are you nursing? YesNo Taking birth control pills? YesNo Medications List any medications you are currently taking: I will list my medications belowNone Allergies Check all that apply (required): NoneAspirinBarbiturates (Sleeping pills)CodeineIodineLatexLocal AnestheticPenicillinSulfaOther Other: Privacy Practices and Office Policies Referral Policy I understand and agree that in the event that I am referred to another medical/dental professional my x-rays and patient history may be shared directly with that referred practice/professional. Privacy Practices and Acknowledgement A hardcopy of our HIPAA Privacy Practices are available to all patients in the office. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. I would like to receive a copy of the HIPAA Privacy Practices upon arrival of my first appointment to the office.I would like to decline receiving a copy of the HIPAA Privacy Practices. I understand that it is my responsibility to request a copy in the future should I change my mind. Authorization to Discuss Protected Health Information I give permission to verbally discuss the following dental/medical and billing information about me: Scheduling/Appointment Information, Medical/Dental Information; including my symptoms, diagnosis, medications & treatment plan, (this may also include information about behavioral health, chemical dependency, prenatal care, pregnancy, family planning & STD testing/treatment) Lab Test Results, Billing & Payment Information etc. I understand that if an individual is not listed here my information will not be released and it is my responsibility as the patient to update and amend/cancel this form in writing. I understand that by not listing an individual on this form that the office will not release any information to them without an amended form in writing. I understand that if I am completing this information under "Power of Attorney" I will need to provide documentation to The Denture Doctor for their records. Appointment Text Message/E-Mail Reminders/Social Media Satisfaction Review Policy By consenting below, you opt-in to receive appointment text messages and/or email reminders/communication with our office. Our text/e-mail communication also consists of a link in order to submit a review of your recent experience. You DO NOT need to click on the link to give a review, it is optional. (Text message rates may apply within your cell phone plan and all fees associated are not the responsibility of The Denture Doctor. It is the responsibility of the patient to update this form and any contact information associated with their account.) I consent to receive text messages and/or e-mails regarding my future appointments and experience at The Denture Doctor.I DECLINE to receive text messages and/or e-mails regarding my future appointments and experience at The Denture Doctor. Additional Notes:
