New Med/Dent History Form Toothworx

Date *

MonthDayYear
Name*

PrefixFirst NameMiddle NameLast Name
Date Of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like us to contact you primarily?*

Cell PhoneHome PhoneWork PhoneEmail
Please state your email address
We require at least one working number: Phone Number - Office

Area CodePhone Number
Phone Number - Cell*

Area CodePhone Number
Phone Number - Home

Area CodePhone Number
Emergency Contact*

First NameLast Name
Relationship of Emergency Contact to Patient*
Phone Number of Emergency Contact*
Please enter a valid phone number.
Please select which Insurance Company you are covered under:*

BF&M/GEHICG InsuranceArgus/Future CareHIPNo Dental Insurance
Insurance Group Number
Insurance Certificate Number
How did you hear about us?*
Date of Last Dental Visit (if you don't remember, please write don't remember:*
Name of Previous Dentist*
Have you ever been told you must take an antibiotic before your dental appointment?*

Yes and I still doYes but I no longer require itNo
At my last dental visit, the practice completed the following:*

x-raysdental scaling/polishingcheck up by the dentista restorative appointment for either fillings, crowns, implants etc.I can't remember, it has been too long
Have you ever had an adverse reaction to any dental treatment?*
Do you have a fear of the dentist?*

Yes, restorative and hygiene appointmentsYes, but just restorative appointments with the dentistNo
Do you use an electric or manual toothbrush?*

ManualElectricBoth
How many times a day do you brush your teeth?*

More than twice a dayTwice a dayOnce a dayA couple times a week or less
Please let us know if you are consistent (daily use) with any of the following:*

FlossStimudentSoft pick/ProxabrushWaterpikEnd tuft brushI don't use anything consistently to clean between my teeth
Do you have a Nightguard?*

Yes and I wear itYes but I DO NOT wear itNo
Do you suffer from mouth ulcers often?*

YesNo
Do your gums bleed when you brush, floss or eat?*

YesNoSometimes
Are your teeth sensitive to hot, cold, sweet or pressure?*

Yes HeatYes ColdYes BiteYes SweetNo
Are you currently experiencing any pain or discomfort in your teeth, gums or jaw?*
Have you previously had any teeth removed? Are they replaced with anything?*
Are you happy with your smile?*
If no, is this something you would like us to address?
Do you suffer from bad breath frequently?*

YesNoon occasion
Have you previously had Orthodontic Treatment (braces)*

YesNo
Have you ever had Periodontal (gum) Treatment?*

YesNo
If yes, was it completed?
Do you find you consistently trap food between your teeth?*

YesNo
What, if any, are your oral habits?*

CoffeeTeaRed WineFingernail bitingcheek biting as a habitgrinding/clenching of teethHigh frequency of sugary drinks (soda, juice, sports drinks)High frequency of carbonated water/drinks (daily or every other day)Lemon/fruit in water at least once a daySnacking/eating frequenty (more than 3x/day)SnoringDiagnosed Sleep ApneaSmoking (Tobacco and/or Marijuana)VapingAlcoholChewing/sucking on mintsChewing gum frequentlyEat fruit more than once a day or suck on fruitNo oral habits listed
Medical Information
Name of Physician*
List of Medications and amounts you currently take (if none, write none)*
Do you suffer from any of the following:*

No known ConditionsArthritisAnemiaAbnormal BleedingAutoimmune diseaseAsthmaAIDS/HIVArtificial JointsArtificial Heart ValveHigh Blood PressureLow Blood PressureCongestive Heart FailureCongenital Heart DefectCardiovascular DiseaseCancerCOPDCrohn's DiseaseDiabetes Type INo known ConditionsDiabetes Type IIEating DisorderEmphysemaEpilepsyFainting or seizuresGI disturbancesGastric RefluxGlaucomaHepatitisKidney ProblemsMental Health DisorderNeurological DisorderNeck/Shoulder pain (Chronic)Osteopenia/OsteoporosisSevere Headaches/MigrainesSevere/Rapid Weight LossStroke/TIASleep ApneaThyroid (Hypo/Hyper) conditionUlcersChronic TonsilitisOther:
Please let us know if anyone in your extended family suffers from any of the following - Heart Disease (heart attack, stroke, TIA, High blood pressure) Diabetes, Cancer, Alzheimers or does anyone wear dentures? *
Amount of Exercise/Week*

3 or more times/week for at least 30 minutes1-3 times/week for at least 30 mintuesA few times a monthRarely
Have you been hospitalized for any serious illness or operation in the last 5 years?*
Please list any allergies (write none if you do not have any):*
Office Policies and Financial Agreement

It is our desire to provide the highest quality of dental care to everyone. The following is a statement of Toothworx’s Financial and Confidentiality Policies. We ask that you please read, agree to, and sign before any treatment is rendered.

Confidentiality and Taking/Receiving of Records

All information gathered at Toothworx regarding your care is kept confidential. I agree to the disclosure of my personal information including visual, written, oral, electronic, photographic or x-ray between any dentists that I am referred to and/or my medical doctors. I consent to the taking of photographs and x-rays by professionals at Toothworx as they are necessary for the diagnosis procedure and record keeping. I also consent to Toothworx receiving my dental records on my behalf from previous dental practices to ensure proper continuity of care.

Regarding Insurance

Our goal is to maximize your insurance benefits. It is important to understand that the insurance contract is between the insurance company and you, the insured. Dental insurance was not designed to pay for all dental care. Treatment recommended by the dentist is never based on what your insurance company will or will not pay. Due to pending claims and patient privacy issues, we do not always know how much an insurance company has already paid out or the balance remaining on a yearly maximum.

Please be prepared to show your insurance card at the time of your visit. It is the patient’s responsibility to provide any new information regarding insurance. At the time of treatment the patient/guardian is responsible for the estimated portion the insurance does not cover (copay). If for some unforeseen reason your insurance carrier has denied or not made payment within 60 days, the patient/guardian is responsible for the balance in full.

Collection Accounts

If after 30 days the account is still outstanding, we will follow up with the insurance company. For those with no insurance, full payment is requested at the time of service. If after 30 days the account is still outstanding, finance charges will be applied to your account and the client will be responsible for these charges. After 90 days your account will be submitted to the Bermuda Credit Association for collection, with an additional surcharge added to the account to cover costs for collection. This percentage is dependent of how long the account is in arrears.

You will also be dismissed from our practice at that time.

Cancellations and Missed Appointments

The entire team here at Toothworx makes every effort to accommodate you and your busy schedule. If you are unable to keep an appointment, we ask that you kindly provide us with minimum of two‐business days’ notice. Our office does not accept cancellation or changes to appointments after hours by voice mail; you must call during our normal business hours. This courtesy on your part will make it possible to give your appointment to another patient who needs to see the dentist or hygienist.

Office Hours:

Monday and Tuesday 8:40am-5:00pm

Wednesday 7:30am-6:00pm

Thursday 8:40am-6:00pm

Friday – 8:40am-2:00pm

I have read, understand and agree to the above Office Policies and Financial Agreements.
I have read and agree to all of Toothworx Policies and Procedures*

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