MEDICAL HISTORY
Patient Name (Please Print) | Birth Date |
Although dental personnel primarily treat the area on and around your mouth, your mouth is a part of your entire body. Health problems that your may have, or medication that you may be taking could have an important interrelationship with the dentistry you will receive.
Are you under a physician’s care now? | YES | NO | If yes, explain |
Have you ever been hospitalized/had a major operation? | YES | NO | If yes, explain |
Have you ever had a serious head or neck injury? | YES | NO | If yes, explain |
Are you taking any medications, pills, or drugs*? | YES | NO | If yes, explain |
Do you take, or have you taken, | YES | NO | If yes, explain |
Have you ever taken Fosamax, Boniva, Actonel or any |
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other medications containing bisphosphonates? | YES | NO | If yes, explain |
Are you on a special diet? | YES | NO | If yes, explain |
Do you use tobacco? | YES | NO | If yes, explain |
Do you drink alcohol? | YES | NO | If yes, how much: |
Do you use controlled substances? | YES | NO | If yes, explain |
Are you pregnant/trying to get pregnant? | YES NO | Est. Due Date: | Nursing YES NO | |||||||||||
Are you taking oral contraceptives? | YES NO | |||||||||||||
Are you allergic to any of the following? | ||||||||||||||
Aspirin Penicillin CodeineLocal AnestheticsAcrylic Metal Latex Sulfa DrugsOtherNo known allergies | ||||||||||||||
Please explain: | ||||||||||||||
Do you have, or have you had, any of the following: |
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AIDS/HIV Positive | YES | NO | Convulsions | YES | NO | Heart Pacemaker | YES | NO |
| Pain in Jaw Joints | YES | NO | ||
Alzheimer's Disease | YES | NO | Cortisone Medicine | YES | NO | Heart Trouble/Disease | YES | NO |
| Parathyroid Disease | YES | NO | ||
Anemia | YES | NO | Diabetes | YES | NO | Hemophilia | YES | NO |
| Psychiatric Care | YES | NO | ||
Angina | YES | NO | Drug Addiction | YES | NO | Hepatitis A | YES | NO |
| Radiation Treatments | YES | NO | ||
Arthritis/Gout | YES | NO | Easily Winded | YES | NO | Hepatitis B or C | YES | NO |
| Recent Weight Loss | YES | NO | ||
Artificial Heart Valve | YES | NO | Emphysema | YES | NO | High Blood Pressure | YES | NO |
| Renal Dialysis | YES | NO | ||
Artificial Joint | YES | NO | Epilepsy & Seizures | YES | NO | High Cholesterol | YES | NO |
| Rheumatic Fever | YES | NO | ||
Asthma | YES | NO | Excessive Bleeding | YES | NO | Hives or Rash | YES | NO |
| Rheumatism | YES | NO | ||
Blood Disease | YES | NO | Excessive Thirst | YES | NO | Hypoglycemia | YES | NO |
| Shingles | YES | NO | ||
Blood Transfusion | YES | NO | Fainting /Dizziness | YES | NO | Irregular Heartbeat | YES | NO |
| Sickle Cell Disease | YES | NO | ||
Breathing Problem | YES | NO | Frequent Cough | YES | NO | Kidney Problems | YES | NO |
| Sinus Trouble | YES | NO | ||
Bruise Easily | YES | NO | Frequent Headaches | YES | NO | Leukemia | YES | NO |
| Stomach/Intestinal Disease | YES | NO | ||
Cancer | YES | NO | Genital Herpes | YES | NO | Liver Disease | YES | NO |
| Stroke | YES | NO | ||
Chemotherapy | YES | NO | Glaucoma | YES | NO | Low Blood Pressure | YES | NO |
| Swelling of Limbs | YES | NO | ||
Chest Pains | YES | NO | Hay Fever | YES | NO | Lung Disease | YES | NO |
| Thyroid Disease | YES | NO | ||
Cold Sores/Fever Blisters | YES | NO | Heart Attack/Failure | YES | NO | Mitral Valve Prolapse | YES | NO |
| TB or Respiratory Disease | YES | NO | ||
Congenital Heart Disorder | YES | NO | Heart Murmur | YES | NO | Osteoporosis | YES | NO |
| Yellow Jaundice | YES | NO | ||
Have you ever had any serious illness not listed above? | YES NO | |||||||||||||
Explain: | ||||||||||||||
*If you have any additional medications you may list them on the back of the form. A copy can be scanned into your chart. |
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Signature of Patient, Parent, Guardian |
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Doctor Signature |
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List your medications here
PATIENT REGISTRATION
First Name Last Name Middle Initial
Preferred Name
Address: City: State/Zip:
Home Ph: Cell Ph: Work Ph: Ext:
Sex: | Male | Female | Status: | Married | Single | Separated | Widowed | NA | |
Birth Date: | Age: | Soc Sec #: Driver’s Lic: | |||||||
Email: | I would like to receive correspondences via email |
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Referred By: |
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Emergency Contact: | Emergency Ph.: |
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Physician’s Name: | Physician’s Ph.: |
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Preferred Pharmacy: | Pharmacy Ph.: |
Employer: | Occupation: |
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Employment Status: | Full Time Part Time Retired | ||||
Student Status: | Full Time Part Time | ||||
Responsible Party (if someone other than the patient) |
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First Name: Last Name: Middle Initial:
Address: City, State, & Zip:
Home Ph.: Work Ph.: Ext: Cell Ph.:
Birthdate: Soc Sec #: | Driver’s Lic: | ||
Responsible Party is also Policy Holder for Patient | Primary Insurance Policy Holder | Secondary Insurance Policy Holder | |
Primary Insurance Information: |
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Name of Insured: | Relationship to Patient: Self Spouse | Child Other |
Insured Soc. Sec: Employer:
Insurance Co: ID #: Group #:
Insurance Subscriber Address if different from patient:
Secondary Insurance Information:
Name of Insured: Relationship to Patient: Self Spouse Child Other
Insured Soc. Sec: Insured Birth Date: Employer:
Insurance Co: ID #: Group #:
Insurance Subscriber Address if different from patient:
Patient Signature:
FINANCIAL AGREEMENT
Our goal at Pioneer Dental Group is to provide our patients with the highest quality dental care possible while utilizing the highest quality materials, technology, and education tools available. Our financial policy is intended to facilitate excellent service while minimizing our administrative costs. Our office strives to give our patients the most accurate estimate of their dental investment as possible and does expect full payment at the time of service. All charges you incur are your responsibility regardless of your insurance. As your dental care provider our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employers, and the insurance company. Our office is not a part of that contract. If payment from your insurance company has not been received within 60 days of the date of service you will be expected to pay the balance in full.
As a courtesy, our office will help to process all of your insurance claims. By signing below, you are authorizing your insurance company to pay your benefits directly to our office. In order for our office to file your insurance claims, you must bring a completed dental insurance form or proof of insurance at each appointment.
Our office accepts cash, personal checks, Mastercard, Visa, Discover, American Express, and offers payment plans through third party financing. If you would like more information regarding the third party financing please check with the financial coordinator.
Returned checks and balances older than 60 days may be subject to collection fees and finance charges at the rate of 1.5% per month. (18% annually). Our office scheduled your dental appointments carefully. Time, trained personnel and dental equipment are reserved for each procedure so we request that you give our office 48 hours’ notice if you need to cancel or reschedule your appointment. Cancellations are not taken via
Print Name of Patient or Responsible Party | Relationship |
Signature of Patient or Responsible Party | Date |
PRIVACY NOTICE ACKNOWLDEGEMENT
To Our Patients:
Federal Law requires that we provide you with a copy of our Privacy Notice.
The Privacy Notice explains how we may use and disclose health information about you. We ask that you sign this form for our records so that we may document your receipt of the notice.
If you have questions about the Privacy Notice, please feel free to direct these to our Privacy Officer at any time. The name and contact number of the Privacy Officer is listed on your copy of the Privacy Notice.
Printed Patient Name: | Date of Birth: |
I have received a copy of the Privacy Notice of this organization on today’s date.
Signed: | Date: |
Consent to Share
If you would like us to discuss your account or treatment plan with someone other than yourself, please indicate them below:
Release to: | Personal | Financial |
If patient is unable to acknowledge receipt, staff member providing notice needs to complete this section
Privacy Notice was provided to
Name:Relation to Patient:Date:
Patient was unable to acknowledge receipt of the Privacy Notice for the following reason:
Signed :
Signature Pad