Dental History

Medical & Dental History Questionnaire

Six Points Plaza Dental
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dental Insurance
Subscriber Name
Insurance Card

Cancelof
Subscriber DOB

MonthDayYear
Date
Relationship to Subscriber
Dental Questionnaire

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Please answer the following if other please describe below*

	Yes	No	Other
Have you ever had adverse reaction to any medication or injections?
Are you anxious about dental treatment?
Are you happy with the appearance of your teeth?
Do you drink coffee, tea or red wine?
Do your gums bleed?
Do you brush and floss regularly?
Do you have hot/cold and or sweet sensitivity?
Do you get food caught in between your teeth?
Do you have any missing teeth?
Do you wear dentures?
Have you ever had a periodontal treatment?
Do you have or have had orthodontics/braces?
Have you had any injury to your jaw/face?
Do you have popping or clicking in the jaw?
Do you clench or grind your teeth?
Do you have a night guard?
Do you snore or have you been diagnosed with sleep apnea?

Do you have any dental concerns?*
Last Dental Visit

MonthDayYear
Date
Last Cleaning Visit

MonthDayYear
Date
Medical Questionnaire

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently under the care of a Physician?*

YesNo
Family Physician:
When was your last Physical?

MonthDayYear
Date
Has there been any change to your general health in the past year including hospitalizations, illnesses or surgeries?*

YesNo
If yes, please give a detailed description.*
Please list all medications, non prescription drugs or herbal supplements.*
Upload Pharmacy List here:

Cancelof
Do you have any allergies, eg: latex, food, environmental?*

YesNo
If yes, please indicate.*

Please answer the following. *

	Yes	No	Unsure
Do you have or ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?
Do you have a prosthetic or artificial joint? If yes, please provide details below including when the surgery was done.
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitailzed for any illness or operations?

Do you have or ever had the following? Please check.*

	Yes	No	Unsure
chest pain, angina
heart attack
stroke, TIA
heart murmur
rheumatic fever
mitral valve prolaspe
tuberculosis
cancer
pacemaker
lung disease
stomach ulcers
arthritis
steroid therapy
diabetes
thyroid disease
drug/alcohol/cannabis use or dependency
seizures
kidney disease
shortness of breath
osteoporosis medications

Please provide any additional information if you answered yes, or unsure in the previous sections.*
Do you have any other conditions not mentioned above? Please indicate.*
Do you or have ever smoked or used tobacco or Marijuana? Please describe type, frequency and duration.*
Are you currently pregnant or breastfeeding?*

YesNo
Do you identify as a patient with a disability? If yes, please indicate below.*

YesNoNot Sure/Maybe
I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.Signature Date
INFORMED CONSENT / GENERAL RELEASE

I the undersigned, certify that I have provided an accurate and complete personal and medical / dental history and have not knowingly omitted any information. I have had the opportunity to ask questions regarding my medical / dental history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for all fees associated with these services. I give this office consent to contact me via email or phone for appointments and newsletters.

Financial Policies

In our continued commitment to provide the highest quality dental care to all of our patients and to make those services comfortably affordable, we are pleased to offer you these payment options. We will, as a courtesy, process your insurance benefits in our office, which will relieve you of this time consuming and sometimes complicated task. We are committed to support you in understanding your dental health, so that you will always be able to make the best choices.

I agree that I am fully responsible for the total payment of all procedures performed in this office - this includes any treatment that is not a benefit of any dental insurance that I may have.

Cancellation Policy

Appointments times are reserved especially for you. lf you come in late, the Doctor may request that you reschedule the appointment and you may be charged a fee of $75. lf for any reason you should need to change your appointment, there will be no charge, provided you give us 2 business days’ notice. lf an appointment is cancelled with less than 48 hrs, a potential fee of $50 may be applied to your account. We are here to assist you in any way possible. Please make your questions and concerns know to our team. Our goal is to ensure that you have an outstanding experience.

HOW OUR OFFICE COLLECTS, USES AND DISCLOSES PATIENTS’ PERSONAL INFORMATION

Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined below how our office is collecting, using and disclosing your personal information.
This office will collect, use and disclose information about you for the following purposes:
- To assess your health needs and provide safe and efficient dental care.
- To enable us to contact and maintain communication with you to distribute healthcare information and to book and confirm appointments.
- To communicate with other treating health-care providers, including other dentists, physicians, pharmacists, and lab technicians.
- For teaching and demonstrating purposes on an anonymous basis.
- To complete and submit dental claims for third party adjudication and payment.
- To comply with legal and regulatory requirements.
- To deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, as necessary.
- To invoice for goods and services.
- To process credit card payments.
- To collect unpaid accounts.
- Thank you for your support and understanding in helping our office to comply with all regulatory requirements, and generally with the law.
I have read and understand the Privacy Police Statement:
Patient Signature*

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