Page 1Page 2Page 3Page 4 Order NumberPatient Information Patient First Name * Patient Last Name * Email Address * Date of Birth * Social Security Number Drivers License Number Gender * Male Female Marital Status * Single Married Divorced Widowed Street Address * Street Address 2 City * State * - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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? * YesNo Payment Information Person Responsible for Payment * Self Parent/Guardian Other Insurance Information Do you have Medical Insurance? * YesNo Medical Insurance Company Medical Insurance ID Number Do you have Dental Insurance? * YesNo 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 No 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 No Do you like your smile? * Yes No Do your gums bleed at any time? * Yes No Do you have any problems with dry mouth? * Yes No Do you ever feel nervous about having dental treatment? * Yes No Are you allergic to any medications (ie. Penicillin, Aspirin, Codeine) * Yes No Do you smoke? * Yes No 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? * YesNo 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 *
