2021 New Patient/Dental/Medical Form

2021 New Patient/Dental/Medical Form
Date
Patient Name *

First Name Last Name
Nickname
Date of Birth
Age
Soc Sec Number
Sex

Male Female
Address
City
State
Zip
Email
example@example.com
Cell number
Home number
Work number
Preferred contact method

email text call
Are you in college

Yes No
Full or part time

Full time Part time
School and location
Occupation
Employer
Spouse Name
Spouse Date of Birth
Who may we thank for referring you to our office
Emergency Contact Name
Contact phone
Do you have any of the following

Bad Breath Clicking or popping jaw Jaw / Face Pain Fingernail biting Lip / Cheek Biting Swollen gums Grinding Teeth Burning tongue/mouth Bleeding Gums Mouth Pain Loose / Broken teeth Tobacco Use Chew on one side of mouth Dry mouth Mouth Breathing Blisters / Mouth sores
History of Orthodontics
When / Where
Appointments:
We reserve time and dental personnel for every patient's appointment. Please consider your appointment with us as confirmed when made. We certainly will provide the courtesy of reminders to you as an added benefit of being our patient.

Should you need to reschedule an appointment please give us a 24-48 hour notice so that we can utilize the time for another patient or continuing education. There is a fee for last minute cancellations or rescheduling.
Patient Initials-1 *
Financial Protocol:
All Dental Treatment Fees are Due at Time service is rendered. If additional help is required, we can offer up to 3 payments with a Credit Card on file for Auto Payments up to 89 days.

We Offer Care Credit or Lending Club for Extended Payments up to 6 Months.

We are happy to process Dental Benefit claims on your behalf to maximize any dental benefits you have. Many Dental practices do not file dental claims for patients anymore.

Rest assured that we will file and wait for the benefit payments assigned to us. However, we request you to please not consider us as your Insurance agents and we expect you to pay your estimated share of treatment fees at the time of service. If any Claim goes Unpaid beyond 60 Days it will become the Responsibility of the Patient.
Patient Initials-2 *
Notice of Privacy:
We are legally required to maintain the privacy of your health information. You have a right to look at the copies of your health information.
Patient Initials-3 *
Do you have Dental Coverage
Dental Coverage Name
Assignment and release for insurance billing:
I certify that I, and or my dependent(s), have dental benefit coverage and assign directly to Dr. Priti S. Bloor all of the insurance benefits, if any, otherwise payable to me for services rendered. I understand I am responsible for all charges paid by insurance or not. I authorize the use of my signature on all insurance submissions. The above named dentist may use my health care information and may disclose such information to the insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for services.
Patient Initials-4 *
Who is responsible for this account
Birthdate
Subscriber Name
Subscriber SSN
Group number
Relationship to Patient
Signature-1 *
Parental Consent and Responsible Party Statement:
Parental Consent is required for any unaccompanied minor child under the age of 18. We will treat unaccompanied Minor children as long as Parent/Guardian is available by Phone and the Parent/Guardian has signed Permission To Treat Consent Form and Medical History prior to Appointment.
I give permission to Bloor Dentistry to perform all dental treatment
on my child,
Parent or Guardian
regardless of my presence in the office. I understand and agree to Bloor Dentistry's Treatment of Minor Consent Form. I agree to pay for all Services Provided to my child.
Name of Child
Name of Parent or Guardian
Signature-2
Relationship to child
Contact number
Signature Date-2
Dental History
How would you rate the condition of your mouth

Excellent Good Fair Poor
Previous Dentist
How long have you been a patient
Months / Years
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than a cleaning)
I routinely see my dentist every

3 mo 4 mo 6 mo 12 mo Not routinely
What is your immediate concern
Please answer Yes or No to the following:

Personal History
Are you fearful of dental treatment?

Yes No
How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience

Yes No
Have you ever had complications from past dental treatment

Yes No
Have you ever had trouble getting numb or had any reactions to local anesthetic

Yes No
Did you ever have braces, orthodontic treatment or had your bite adjusted,

Yes No
At what age
Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma

Yes No
Gum and Bone
Do your gums bleed or are they painful when brushing or flossing

Yes No
Have you ever been treated for gum disease or been told you have lost bone around your teeth

Yes No
Have you ever noticed an unpleasant taste or odor in your mouth

Yes No
Is there anyone with a history of periodontal disease in your family

Yes No
Have you ever experienced gum recession

Yes No
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple

Yes No
Have you experienced a burning or painful sensation in your mouth not related to your teeth

Yes No
Tooth Structure
Have you had any cavities within the past 3 years

Yes No
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food

Yes No
Do you feel or notice any holes (ie pitting, craters) on the biting surface of your teeth

Yes No
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth

Yes No
Do you have grooves or notches on your teeth near the gum line

Yes No
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling

Yes No
Do you frequently get food caught between any teeth

Yes No
Bite and Jaw Joint
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes No
Do you feel like your lower jaw is being pushed back when you bite your back teeth together

Yes No
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods

Yes No
In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed

Yes No
Are your teeth becoming more crooked, crowded, or overlapped

Yes No
Are your teeth developing spaces or becoming more loose

Yes No
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together

Yes No
Do you place your tongue between your teeth or close your teeth against your tongue

Yes No
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits

Yes No
Do you clench or grind your teeth together in the daytime or make them sore

Yes No
Do you have any problems with sleep (ie restlessness or teeth grinding), wake up with a headache or an awareness of your teeth

Yes No
Do you wear or have you ever worn a bite appliance

Yes No
Smile Characteristics
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)

Yes No
Have you ever whitened (bleached) your teeth

Yes No
Have you felt uncomfortable or self conscious about the appearance of your teeth

Yes No
Have you been disappointed with the appearance of previous dental work

Yes No
Patient Signature-2 *
Date-2
Medical History
Name of Physician and specialty
Most recent physical exam
Purpose
What is your estimate of your general health

Excellent Good Fair Poor
DO YOU HAVE or HAVE YOU EVER HAD:
hospitalization for illness or injury

Yes No
an allergic or bad reaction to any of the following

aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) Iodine metals (nickel, gold, silver) latex nuts fruit milk red dye other
if other is checked, please list allergies
heart problems, or cardiac stent within the last six months

Yes No
history of infective endocarditis

Yes No
artificial heart valve, repaired heart defect (PFO)

Yes No
pacemaker or implantable defibrillator

Yes No
orthopedic or soft tissue implant (eg joint replacement, breast implant)

Yes No
heart murmur, rheumatic or scarlet fever

Yes No
high or low blood pressure

Yes No
a stroke (taking blood thinners)

Yes No
anemia or other blood disorder

Yes No
prolonged bleeding due to a slight cut

Yes No
pneumonia, emphysema, shortness of breath, sarcoidosis

Yes No
chronic ear infections, tuberculosis, measles, chicken pox

Yes No
breathing problems (eg asthma, stuffy nose, sinus congestion)

Yes No
sleep problems (eg sleep apnea, snoring, insomnia, restless sleep, bedwetting)

Yes No
kidney disease

Yes No
liver disease or jaundice

Yes No
vertigo (eg 'the room is spinning')

Yes No
thyroid, parathyroid disease, or calcium deficiency

Yes No
hormone deficiency or imbalance (eg poly cystic ovarian syndrome)

Yes No
high cholesterol or taking statin drugs

Yes No
diabetes

Yes No
stomach or duodenal ulcer

Yes No
digestive or eating disorders (eg celiac disease, gastric reflux, bulimia, anorexia)

Yes No
osteoporosis/osteopenia or ever taken anti-resorptive medications(eg bisphosphonates)

Yes No
arthritis or gout

Yes No
autoimmune disease (eg rheumatoid arthritis, lupus, scleroderma)

Yes No
glaucoma

Yes No
contact lenses

Yes No
head or neck injuries

Yes No
epilepsy, convulsions (seizures)

Yes No
neurologic disorders (Alzheimers, dementia, prion disease)

Yes No
viral infections and cold sores

Yes No
any lumps or swelling in the mouth

Yes No
hives, skin rash, hay fever

Yes No
STI/STD/HPV

Yes No
hepatitis

Yes No
HIV/AIDS

Yes No
tumor, abnormal growth

Yes No
radiation therapy

Yes No
chemotherapy, immunosuppressive medication

Yes No
emotional difficulties

Yes No
psychiatric treatment or antidepressant medication

Yes No
concentration problems or ADD/ADHD

Yes No
alcohol/recreational drug use

Yes No
ARE YOU:
presently being treated for any other illness

Yes No
aware of a change in your health in the last 24 hours(eg fever, chills, new cough, or diarrhea

Yes No
taking medication for weight management

Yes No
taking dietary supplements, vitamins, and/or probiotics

Yes No
often exhausted or fatigued

Yes No
experiencing frequent headaches or chronic pain

Yes No
a smoker, smoked previously or other (eg smokeless tobacco, vaping, e-cigarettes, and canabis)

Yes No
considered a touchy/sensitive person

Yes No
often unhappy or depressed

Yes No
taking birth control pills

Yes No
currently pregnant

Yes No
diagnosed with a prostate disorder

Yes No
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect yourdental treatment. (ie Botox, Collagen Injections)
List all medications, supplements, vitamins and/or probiotics taken within the last two years
Drug / Purpose
Patient Signature-3 *
Date-3
Should be Empty: