2022 New Patient/Dental/Medical Form

2022 New Patient/Dental/Medical Form
Date
Patient Name*

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

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

emailtextcall
Are you in college

YesNo
Full or part time

Full timePart 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 BreathClicking or popping jawJaw / Face PainFingernail bitingLip / Cheek BitingSwollen gumsGrinding TeethBurning tongue/mouthBleeding GumsMouth PainLoose / Broken teethTobacco UseChew on one side of mouthDry mouthMouth BreathingBlisters / 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. Joseph Moore 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 Moore Dentistry to perform all dental treatment
on my child,
Parent or Guardian
regardless of my presence in the office. I understand and agree to Moore 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

ExcellentGoodFairPoor
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 mo4 mo6 mo12 moNot routinely
What is your immediate concern
Please answer Yes or No to the following:

Personal History
Are you fearful of dental treatment?

YesNo
How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience

YesNo
Have you ever had complications from past dental treatment

YesNo
Have you ever had trouble getting numb or had any reactions to local anesthetic

YesNo
Did you ever have braces, orthodontic treatment or had your bite adjusted,

YesNo
At what age
Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma

YesNo
Gum and Bone
Do your gums bleed or are they painful when brushing or flossing

YesNo
Have you ever been treated for gum disease or been told you have lost bone around your teeth

YesNo
Have you ever noticed an unpleasant taste or odor in your mouth

YesNo
Is there anyone with a history of periodontal disease in your family

YesNo
Have you ever experienced gum recession

YesNo
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple

YesNo
Have you experienced a burning or painful sensation in your mouth not related to your teeth

YesNo
Tooth Structure
Have you had any cavities within the past 3 years

YesNo
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food

YesNo
Do you feel or notice any holes (ie pitting, craters) on the biting surface of your teeth

YesNo
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth

YesNo
Do you have grooves or notches on your teeth near the gum line

YesNo
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling

YesNo
Do you frequently get food caught between any teeth

YesNo
Bite and Jaw Joint
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

YesNo
Do you feel like your lower jaw is being pushed back when you bite your back teeth together

YesNo
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods

YesNo
In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed

YesNo
Are your teeth becoming more crooked, crowded, or overlapped

YesNo
Are your teeth developing spaces or becoming more loose

YesNo
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

YesNo
Do you place your tongue between your teeth or close your teeth against your tongue

YesNo
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits

YesNo
Do you clench or grind your teeth together in the daytime or make them sore

YesNo
Do you have any problems with sleep (ie restlessness or teeth grinding), wake up with a headache or an awareness of your teeth

YesNo
Do you wear or have you ever worn a bite appliance

YesNo
Smile Characteristics
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)

YesNo
Have you ever whitened (bleached) your teeth

YesNo
Have you felt uncomfortable or self conscious about the appearance of your teeth

YesNo
Have you been disappointed with the appearance of previous dental work

YesNo
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

ExcellentGoodFairPoor
DO YOU HAVE or HAVE YOU EVER HAD:
hospitalization for illness or injury

YesNo
an allergic or bad reaction to any of the following

aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridechlorhexidine (CHX)Iodinemetals (nickel, gold, silver)latexnutsfruitmilkred dyeother
if other is checked, please list allergies
heart problems, or cardiac stent within the last six months

YesNo
history of infective endocarditis

YesNo
artificial heart valve, repaired heart defect (PFO)

YesNo
pacemaker or implantable defibrillator

YesNo
orthopedic or soft tissue implant (eg joint replacement, breast implant)

YesNo
heart murmur, rheumatic or scarlet fever

YesNo
high or low blood pressure

YesNo
a stroke (taking blood thinners)

YesNo
anemia or other blood disorder

YesNo
prolonged bleeding due to a slight cut

YesNo
pneumonia, emphysema, shortness of breath, sarcoidosis

YesNo
chronic ear infections, tuberculosis, measles, chicken pox

YesNo
breathing problems (eg asthma, stuffy nose, sinus congestion)

YesNo
sleep problems (eg sleep apnea, snoring, insomnia, restless sleep, bedwetting)

YesNo
kidney disease

YesNo
liver disease or jaundice

YesNo
vertigo (eg 'the room is spinning')

YesNo
thyroid, parathyroid disease, or calcium deficiency

YesNo
hormone deficiency or imbalance (eg poly cystic ovarian syndrome)

YesNo
high cholesterol or taking statin drugs

YesNo
diabetes

YesNo
stomach or duodenal ulcer

YesNo
digestive or eating disorders (eg celiac disease, gastric reflux, bulimia, anorexia)

YesNo
osteoporosis/osteopenia or ever taken anti-resorptive medications(eg bisphosphonates)

YesNo
arthritis or gout

YesNo
autoimmune disease (eg rheumatoid arthritis, lupus, scleroderma)

YesNo
glaucoma

YesNo
contact lenses

YesNo
head or neck injuries

YesNo
epilepsy, convulsions (seizures)

YesNo
neurologic disorders (Alzheimers, dementia, prion disease)

YesNo
viral infections and cold sores

YesNo
any lumps or swelling in the mouth

YesNo
hives, skin rash, hay fever

YesNo
STI/STD/HPV

YesNo
hepatitis

YesNo
HIV/AIDS

YesNo
tumor, abnormal growth

YesNo
radiation therapy

YesNo
chemotherapy, immunosuppressive medication

YesNo
emotional difficulties

YesNo
psychiatric treatment or antidepressant medication

YesNo
concentration problems or ADD/ADHD

YesNo
alcohol/recreational drug use

YesNo
ARE YOU:
presently being treated for any other illness

YesNo
aware of a change in your health in the last 24 hours(eg fever, chills, new cough, or diarrhea

YesNo
taking medication for weight management

YesNo
taking dietary supplements, vitamins, and/or probiotics

YesNo
often exhausted or fatigued

YesNo
experiencing frequent headaches or chronic pain

YesNo
a smoker, smoked previously or other (eg smokeless tobacco, vaping, e-cigarettes, and canabis)

YesNo
considered a touchy/sensitive person

YesNo
often unhappy or depressed

YesNo
taking birth control pills

YesNo
currently pregnant

YesNo
diagnosed with a prostate disorder

YesNo
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: