Existing Patient Forms

--- EXISTING PATIENT FORMS ---
Patient Information, Insurance Information and Health History
Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
Name *

First Name Middle Name Last Name
Email *
example@example.com
If you have been in our office within the last six months, please simply check this box and then submit the form.
Insurance Information

Leave blank if no change or un-insured.
Name of Insured

First Name Middle Name Last Name
Insured's Birth Date

Month Day Year
Date
ID #
Group #
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient's relationship to insured

Self Spouse Child Other
Insurance Plan Name
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Health History
1. What is the reason for your visit today? *
2. When was your last Dental visit and what was done at this time? *
3. How do you feel about the appearance of your teeth? *
4. When was your last Physical exam? *
5. Physician's Name, Phone Number, and Address: *
6. Are you currently under medical treatment? If yes, please describe. *
7. Have you ever had any serious illnesses or operations? If yes, please describe. *
8. Are you currently taking any medication(s) including non-prescription medicine? Please list. *
9. Do you smoke or use tobacco products? If yes, how much a week? *
10. Do you use alcohol? If yes, how much a week? *
11. Do you have artificial or replacement joints, knee, hip, etc? If yes, please list. *
12. Do you have any allergies (food, medications, etc)? If yes, please list. *
Please check all that apply: *

*Pre-Med - Amox *Pre-Med - Clind *Pre-Med - Other Addiction to Drugs Allergy - Anesthesia Allergy - Aspirin Allergy - Codeine Allergy - Erythro Allergy - Hay Fever Allergy - Latex Allergy - Other Allergy - Penicillin Allergy - Sulfa Anemia Angian/Chest Pain Arthritis Artificial Joints Asthma Bleeding Tendency Blood Disease Cancer Current Breast Feeding Diabetes Dizziness Emphysema Epilepsy Excessive Bleeding Fainting Glaucoma Head Injuries Heart Attack Heart Disease Heart Murmur Heart Stent Hepatitis Herpes HIGH ANXIETY High Blood Pressure HIV / AIDS Kidney Disease Liver Disease Lupus (SLE) Medications Mental Disorders Mitral Valve Prolapse Nervous Disorders New Heart Valve Osteoporosis Other Pacemaker Pregnancy Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Shortness of Breath Sinus Problems Stomach Problems Stroke Take Bisphosphonates Thyroid Tuberculosis Tumors Ulcers NONE
Please describe any other medical conditions that were not previously asked. *
Name of person, office, or other source referring you to our office: *
Signature of patient, parent, or guardian (responsible party):
Date *

Month Day Year
Date
Relationship to Patient *
Signature *

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COVID-19 Pandemic Patient Disclosures
This patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 virus outbreak

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature of patient, legal guardian or authorized representative *

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Dental Treatment Consent and Affirmation Form
I knowingly and willingly consent to dental treatment at Telluride Center for Dentistry by Dr. Grady, Dr. Kopasz, Heidi Weaver and Lynsey Bonebrake and any designated associates and employees during the reopening phase of COVID-19.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.

Risk of transmission: I understand that due to the frequency of visits of other care dental patients, characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.

I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting with any of the following symptoms of COVID-19:
- Fever of 100.5 degrees Fahrenheit or 37 degrees Celsius or higher
- Shortness of breath
- Dry cough
- Runny nose
- Sore throat
- Diminished sense of taste or smell
Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less for a duration of fifteen minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 4 (#4) in the last 14 days.

Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.
Signature of patient, legal guardian or authorized representative *

Clear
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--- EXISTING PATIENT FORMS ---

Patient Information, Insurance Information and Health History

Insurance Information

Health History

COVID-19 Pandemic Patient Disclosures

Dental Treatment Consent and Affirmation Form