Chart #:   	
	FOR OFFICE USE ONLY

Patient Information

Patient Name:   	  Date:   	
                                 Last,              First        MI         (Preferred Name)
                                                                                   Gender:   	   Family Status:   	

Social Security #:   	   Birth Date:    	

Phone (Home):   	  (Work):   	 Ext:  	  Best time to call: 	

Preferred appointment times:   Morning    Afternoon    Evening    Any Time    M  T  W  T  F  S

Address:	  		
                            Street                                                                                                                                     Apartment #
	  			
                          City                                                                              State                                          Zip Code

Health Information

Date of Last Dental Visit:   	  Reason for this visit:  	

Have you ever had any of the following?  Please check those that apply:
 AIDS	
 Allergies __________	
                  __________	
 Anemia  	
 Arthritis	
 Artificial Joints	
 Asthma	
 Blood Disease	
 Cancer	
 Diabetes	
 Dizziness	
 Epilepsy	
 Excessive Bleeding	
 Fainting	
 Glaucoma	
 Growths	
 Hay Fever	
 Head Injuries	
 Heart Disease	
 Heart Murmur	
 Hepatitis	
 High Blood Pressure	
 Jaundice	
 Kidney Disease	
 Liver Disease	
 Mental Disorders	
 Nervous Disorders	
 Pacemaker	
 Pregnancy	
    Due date:_________	
 Radiation Treatment	
 Respiratory Problems	
 Rheumatic Fever	
 Rheumatism	
 Sinus Problems	
 Stomach Problems	
 Stroke	
 Tuberculosis	
 Tumors	
 Ulcers	
 Venereal Disease	
 Codeine Allergy	
 Penicillin Allergy	
OTHER:	
 _________________	
	
 _________________	

 Have you ever had any complications following dental treatment?     Yes   No
     If yes, please explain: 	

 Have you been admitted to a hospital or needed emergency care during the past two years?     Yes   No
     If yes, please explain: 	

 Are you now under the care of a physician?     Yes   No
     If yes, please explain: 	

 Name of Physician: _______________________________________________  Phone: 	

 Do you have any health problems that need further clarification?     Yes   No
     If yes, please explain: 	

To the best of my knowledge, all of the preceding answers and information provided are true and correct.  If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

_________________________________________________________________  Date: 	
   Signature of patient, parent or guardian

Referral Information

Whom may we thank for referring you to our practice?    Another patient, friend    Another patient, relative

       Dental Office     Yellow Pages     Newspaper     School     Work     Other 	

Name of person or office referring you to our practice:  	

Spouse or Responsible Party Information
The following is for:    the patient's spouse     the person responsible for payment

Name:   	
                     Male    Female                                Married    Single    Child    Other 	

Social Security #: ________________________________  Birth Date: 	

Phone (Home): ________________ (Work): ________________ Ext: ______  Best time to call: 	

Address: 		
                                  Street                                                                                                                                                                                                         Apartment #
		
                                  City                                                                                                                                                         State                                                 Zip Code

Employment Information
The following is for:    the patient     the person responsible for payment

Employer Name:   	  Occupation: 	

Address:	                              	                              	                              	 

Insurance Information
Primary
Name of Insured: _______________________________________________  Is insured a patient?   Yes    No
                                                           Last                                                            First                                        MI
Insured's Birth Date: _________________  ID #: _____________________  Group #: 	

Insured's Address: 	
                                                                      Street                                                                                              City                                             State                      Zip Code
Insured's Employer Name: 	

              Address: 	
                                                                      Street                                                                                              City                                             State                      Zip Code
      Patient's relationship to insured:   Self    Spouse    Child    Other ___________________

Insurance Plan Name and Address:	  	

Secondary
Name of Insured: _______________________________________________  Is insured a patient?   Yes    No
                                                           Last                                                            First                                        MI
Insured's Birth Date: _________________  ID #: _____________________  Group #: 	

Insured's Address: 	
                                                                      Street                                                                                              City                                             State                      Zip Code
Insured's Employer Name: 	

              Address: 	
                                                                      Street                                                                                              City                                             State                      Zip Code
      Patient's relationship to insured:   Self    Spouse    Child    Other ___________________

Insurance Plan Name and Address:	  	

Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance.  The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services.  This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account.  However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended.  I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof.  I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

____________________________________________________  Date: _____________  Relationship to Patient: 	
Signature of patient, parent or guardian

____________________________________________________  Date: _____________  Relationship to Patient: 	
Signature of guarantor of payment/responsible party