Personal Information Initial:MRMS Date of Birth:JanFebMarAprMayJuneJulyAugSepOctNovDec01020304050607080910111213141516171819202122232425262728293031 Age: Employment Spouse/Domestic Partner/Parent JanFebMarAprMayJuneJulyAugSepOctNovDec01020304050607080910111213141516171819202122232425262728293031 Age: Insurance Information If you have dental insurance, please complete the following and apprise us as any changes occur in your coverage. Primary Coverage Secondary Coverage Insurance Card Front: Insurance Card Back: Insurance Card Front: Insurance Card Back: > Dental History Oral hygiene techniques(multiple selection allowed):ToothbrushFlossWaterpickProxabrushOther Toothbrush type: ManualElectricBoth Referral form: Medical History Are you being treated by a physician for any illness or condition?NoYes Have you had any serious illness/operation/hospitalized?NoYes Do you have any allergic reaction to any medications? e.g. Penicillin, Codeine, AspirinNoYes Is there any family history of any illness/disease, e.g. heart problems, diabetes, cancerNoYes Women: Are you pregnant?NoYes Any medication you had an adverse reaction toNoneaspirinpenicillinerythromycintetracyclinecodeinesedatives/sleeping pillsdental anestheticsother Immune deficiency syndrome(HIV/AIDS)NoYes Please Specify and list all current medications: Have you taken any long term medications in the past? Prescription or Non-PrescriptionNoYes Mark if any of the following apply to you AllergiesAllergy to LatexAnemia/blood disorderArthritisAsthmaBacterial endocarditisBlood transfusionChest painCongestive heart failureDiabetesDrug/Alcohol abuseEmphysemaEpilepsy/SeizuresGlaucomaHeart diseaseHeart murmurHepatitisHigh blood pressureHospitalized for any conditionHyperthyroid/hypothyroidKidney diseaseLiver diseaseLow blood pressureMitral valve prolapsePacemakerPhen-fen/redux/pandimin useProlonged bleedingProsthetic heart valveProsthetic jointsPsychiatric treatmentPulmonary shuntRadiation treatmentRheumatic feverScarlet feverShortness of breathStrokeSwollen anklesTuberculosisTumors/CancerUlcersVenerial diseaseChemotherapyHigh CholesterolMultiple SclerosisAutoimmune diseaseOther (please specify below)SmokerAware of any health change in the past yearAware of any recent weight changeGenerally a nervous personHave you taken or are you taking a Biphosphonate (Fosomax, Boniva, Didrocal, Actonel, Aredia, Zometa)Often exhausted or fatiguedOften thirstyOften unhappy or depressedPresently being treated for illnessUrinating more than six times a dayTaking herbal medicationPostmenopauseTaking birth control pills or hormones Assignment & Release I recognize that I am financially responsible for any services rendered to me at this office. Treatment fees will be presented prior to treatment. Payment in full is appreciated at the time of service. We accept cash, credit cards, and checks. Returned checks will have a $35.00 bank charge applied to the patient account. As a special service to me, insurance claims may be prepared and submitted on my behalf. I hereby authorize this office to release any information to my insurance company that is needed for the filing of my claims. Changes or additions to your insurance must be provided at each appointment for proper insurance submission. We will be unable to resubmit insurance claims due to inaccurate information provided or on file. Appointments A scheduled appointment in our practice is considered a confirmation of your reserved time. If you need to change your future appointment, we kindly request 72 hours advance notice. This will allow us time to find you another reservation, ensuring continued optimal care and avoiding a cancellation fee ($85). Three cancellations may result in dismissal from our care, because it compromises our ability to effectively serve your periodontal needs. Thank you for appreciating our appointment policy Confidentiality I have been informed of this office’s Privacy Policies and have been instructed as to the location of the office wide policy on display so that I may review the policy at my discretion. I also am aware that a copy of these policies are available to me in print if requested. I permit communication between my doctors, dentists, and family members / guardians as is deemed necessary for successful treatment outcomes. Insurance Our office has always been happy to work with patients covered by dental insurance. We think insurance is a great incentive to maintain a vital level of dental health. But it's a rare—very rare—dental plan that covers 100% of our fees. Here's why. The fees we charge for dental services are the same for every patient, insured or not. A given insurance policy, however, is based on a fixed fee schedule—"usual and customary"—that may have nothing to do with the real world. Dentistry has changed very quickly, insurance fee schedules have not. After all, insurance companies are profitable businesses, not dental benefactors. Further, insurance companies reimburse you an amount they figure is commensurate with average quality dentistry in an average office with an average staff, "average" falling somewhere between the best dentistry and the worst dentistry. Well, we have a better opinion of our services. Our belief is, and always has been, that the style and quality of our dentistry had better be the best. We're happy to help you with any insurance questions you have. We'll go over your policy with you, try to maximize your benefits, and request a predetermination of benefits to let you know what your insurer will pay. But please remember your insurer dictates your coverage—we don't. Patient's Signature: Parent/Guardian: After you click send please look at the small "loading wheel" on the right of the button and wait until the form has been submitted. If there are any errors, please review the form again, make sure they are fixed, and then submit. The form has only been successfully submitted once the small spinning wheel on the right of the submit button shows a successful submission. Thank you!