Medical & Dental History

Dental History
What is the reason for your visit?
Date of last Dental Visit?

Month Day Year
Date
Last Dental Cleaning?

Month Day Year
Date
Last Full mouth X-Rays?

Month Day Year
Date
What was done at your last dental visit?
Name of previous Dentist?
Address

Street Address

Street Address Line 2

City State

Zip Code
Do you have dental problems now?

Dental History (continued)

Please select yes or no, then explain when instructed

Yes/No

Explain

Would you like to keep all of your teeth all of your life?

Do you feel nervous about having dental treatment? If yes, please explain.

Do you have any concerns about dental treatment? If yes, please explain.

Have you ever had an upsetting dental experience? If yes, please explain.

Do you use more than two pillows to sleep?

Have you lost or gained more than 10lbs in the past year?

Have you been diagnosed with Osteoporosis/Osteopenia?

Do you take or have you taken Bisphosphonates?

Is there anything else about having dental treatment that you would like us to know?
Who may we contact in case of emergency?

Consent & Signature
1. I understand the previous information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.
2. The undersigned hereby authorizes doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patients’ s dental needs.
3. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk, Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment.
4. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1% finance charge maybe added to my account, in addition to any collection charges.
5. I understand that where appropriate, credit bureau reports may be obtained.
6. I understand that it is my responsibility to advise your office of any changes in the information obtained on this form.
7. I authorize the use of my social security number to file my dental claim.
Date *

Month Day Year
Date
Patient Signature *

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Medical History

Medical History (continued)

Dental History

Dental History (continued)

Dental History (continued)

Consent & Signature