Waldorf Office
Leonardtown Office
Clinton Office
Washington D.C. Office
Charlotte Hall Office
Welcome to
Our
Practice
Thank You for trusting us with your dental care. We promise to do our best to provide you with the finest care available. If you have any questions please do not hesitate to contact us.
Patient#:
SS#:
Date:
PATIENT INFORMATION
Patient’s Name
Last:
First:
Middle:
Male:
Female:
Address:
City:
State:
Zip:
Home Phone:
(
)-
E-mail:
Check Appropriate Box:
Minor:
Single:
Married:
Divorced:
Widowed:
Separated:
Patient’s or Parent’s Employer:
Work Phone:
(
)-
Business Address:
City:
State:
Zip:
Spouse or Parent’s Name:
Employer:
Work Phone:
(
)-
If Patient is a Student, Name of School/College:
City:
State:
Whom May We Thank for Referring You?
Person to Contact in Case of Emergency:
Phone:
(
)-
RESPONSIBLE PARTY
Patient’s Name
Last:
First:
Middle:
Male:
Female:
Address:
City:
State:
Zip:
Home Phone:
(
)-
E-mail:
Driver's License#:
Social Security#:
Bank:
Employer:
Work Phone:
(
)-
Currently a Pattient in our Office
Yes:
No:
INSURANCE INFORMATION
Name of Insured
Last:
First:
Middle:
Male:
Female:
Relation to Patient:
Birthdate:
Soc. Security #:
Employer:
Work Phone:
(
)-
Date Employed:
Employer
Address:
City:
State:
Zip:
Insurance Company:
Group:
Union or Local #:
Address:
City:
State:
Zip:
How Much is Your Deductible?
How Much Have You Used?
Max. Annual Benefit:
ADDITIONAL INSURANCE
Name of Insured
Last:
First:
Middle:
Male:
Female:
Relation to Patient:
Birthdate:
Soc. Security #:
Employer:
Work Phone:
(
)-
Date Employed:
Employer
Address:
City:
State:
Zip:
Insurance Company:
Group:
Union or Local #:
Address:
City:
State:
Zip:
How Much is Your Deductible?
How Much Have You Used?
Max. Annual Benefit:
Reason for today’s visit :
Date of last dental visit :
Former Dentist :
Date of last dental:
X-rays :
Address :
Check (√) if you have had any of the following:
Bad breath
G
rinding teeth
Sensitivity to heat
Bleeding gums
Loose teeth or broken fillings
Sensitivity to sweets
Clicking or popping jaw
Periodontal treatment
Sensitivity when biting
Food collection between the teeth
Sensitivity to cold
Sores or growths in you mouth
How often do you floss?
How often do you brush?
Physician’s Name
Date of last visit
Have you ever taken any of the group of drugs collectively referred to a “fen-phen”? These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes
No
Have you had any serious illnesses or operations? Yes
No
If yes, describe
Have you ever had a blood transfussion? Yes
No
If yes, give approximate dates
(Women) Are you pregnant? Yes
No
Nursing? Yes
No
Taking birth control pills? Yes
No
Check (√) if you have had any of the following:
Anemia
Cortisone Treatments
Hepatitis
Scarlet Fever
Arthritis, Rheumatism
Cough, Persistent
High Blood Preasure
Shortness of Breath
Artificial Heart Valves
Cough up Blood
HIV / AIDS
Skin Rash
Artificial Joints
Diabetes
Jaw Pain
Stroke
Asthma
Epilepsy
Kidney Disease
Swelling of Feet or Ankles
Back Problems
Fainting
Liver Disease
Thyroid Problems
Blood Disease
Glaucoma
Mitral Valve Prolapse
Tobacco Habit
Cancer
Headaches
Pacemaker
Tonsillitis
Chemical Dependency
Heart Murmur
Radiation Treatment
Tuberculosis
Chemotherapy
Heart Problems
Respiratory Disease
Ulcer
Circulatory Problems
Hemophilia
Rheumatic Fever
Venereal Disease
Medications:
Allergies:
List medications you are currently taking and the correlating diagnosis:
I have read and answered the above questions to the best of my knowledge. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all insurance submissions.
Date:
Payment is due in full at time of treatment unless prior arrangements have been approved.