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, Phen-Fen or Redux?	YES	NO	If yes, explain
Have you ever taken Fosamax, Boniva, Actonel or any
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:

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.

Signature of Patient, Parent, Guardian

Date

Doctor Signature

Date

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
Referred By:
Emergency Contact:					Emergency Ph.:
Physician’s Name:					Physician’s Ph.:
Preferred Pharmacy:					Pharmacy Ph.:

Employer:		Occupation:
Employment Status:	Full Time Part Time Retired
Student Status:	Full Time Part Time
Responsible Party (if someone other than the patient)

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:
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:

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 e-mail or voice mail. Missed appointments or late cancellations can be subjected to a $50.00 fee. There will be a $30 duplication fee applied for any unpaid radiographs should they be requested. Pioneer Dental Group is committed to providing you with the best experience in dental care so please do not hesitate to ask if you have any questions regarding our financial agreement.

Print Name of Patient or Responsible Party	Relationship

Signature of Patient or Responsible Party	Date

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 :  

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