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Patient Information

Patient First Name *

Patient Last Name *

Email Address *

Date of Birth *

Social Security Number

Drivers License Number

Gender *

Marital Status *

Street Address *

Street Address 2

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number

Work Phone Number

How did you hear about our office?

Friend/Family Member

Marketing

Website

Insurance Company

Other

Please Specify

Is another member of your family a patient here? *

Yes No

Payment Information

Person Responsible for Payment *

Self

Parent/Guardian

Other

Insurance Information

Do you have Medical Insurance? *

Yes No

Medical Insurance Company

Medical Insurance ID Number

Do you have Dental Insurance? *

Yes No

INSURANCE POLICY: Our office submits to insurance companies as a courtesy to our patients. Any balances not paid by the insurance company are the patient's responsibility. All patient estimates are due at the time of service. If you do not have insurance, full payment is expected at the time of service. All past-due accounts with balances over 30 days old are subject to a service charge of $5 per month late. If it becomes necessary to seek the assistance of an attorney, court costs and attorney fees will be added to your bill to the extent permitted by law. To avoid a missed appointment fee of $25, please give us at least 24 hours advance cancellation notice to reschedule. A broken not only hurts you and the doctor, but permits another patient from being see.

Medical History

Patient's Name *

Have you been under the care of a medical doctor in the last two years?

Yes

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship

Emergency Contact Address

Emergency Contact Address 2

Emergency Contact City

Emergency State

Emergency Zip

Primary Care Physician

Physician Address

Physician Address 2

Physician City

Physician State

Physician Zip

Previous Dentist Name

Date of Last Dental Visit

Date of Last Dental X-Rays

Are you experiencing any dental problems at this time? *

Yes

Do you like your smile? *

Yes

Do your gums bleed at any time? *

Yes

Do you have any problems with dry mouth? *

Yes

Do you ever feel nervous about having dental treatment? *

Yes

Are you allergic to any medications (ie. Penicillin, Aspirin, Codeine) *

Yes

Do you smoke? *

Yes

Check any of the following you have had or currently have: *

Heart Failure

Heart Disease or Attack

Angina Pectoris (chest pain)

Heart Pacemaker

Heart Surgery

Tuberculosis

Asthma

Rheumatic Fever

Scarlet Fever

Artificial Joints

Heart Murmur/Mitral Valve

Stroke

Kidney Trouble

Hepatitis (A, B or C)

Liver Disease

Fainting or Dizzy Spells

Hay Fever

Allergies or Hives

Diabetes

Thyroid Disease

X-Ray or Cobalt Treatment

Chemotherapy

Arthritis

Glaucoma

TMJ/TMD

Cold Sores/Fever Blisters

Hemophilia

Venereal Disease

HIV Positive

Epilepsy or Seizures

Jaundice

Ulcers

Psychiatric Treatment

Sickle Cell Anemia

Bruise Easily

Emphysema

Anemia

Shortness of Breath

High Blood Pressure

None of the above

Are you taking any medications? *

Yes No

My checking the box below you agree that the information provided in the previous pages is accurate to the best of your knowledge. You also give consent to South County Smiles to receive a breakdown of your insurance benefits and to create a chart based on the information provided.

By Checking this box, you agree to the information stated above. *

I agree

Name *

Relationship *

Date *

I am not a robot *

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