Dentistinmckinney.net

So that we may provide you with the best care, please fill out these forms completely. Mr. Mrs. Ms. Dr. Today’s Date Last name First name Middle initial Date of Birth / / Age Prefer to be called Address City State Zip Occupation Employer If married, please list Spouse’s name: If the patient is a minor please fill out the following: Parents or Guardians name: Address City State Zip Person financially responsible for this account is Relationship to patient Phone DL # Address (If different from patient) City State Zip Employer Business phone EXT Method of payment: Cash Check Credit Card If you have insurance and would like our office to assist you in filing, please provide us with the following information. Insurance Company Insured Employee

Employee Social Security Number / Date of Birth Group Number / Date Employed
Authorization for Submission of Claims and Assignment of Benefits I authorize Thompson Dental to submit claims for payment for services to the health care service plan or
insurance company named above on my behalf and in my name, and assign such provider the group
insurance benefits otherwise payable to me. I understand that I am financially responsible for any balances
not satisfied by my insurance benefits, regardless of the basis for nonpayment by my insurance carrier.
Authorization of Release of Health Information I authorize Thompson Dental to provide any insurance company, health care service plan, self insurers or
their representatives, any and all information and records (including x-rays) about my medical history, or
about services rendered or treatment given to me that is needed to review, investigate or evaluate any claim
for benefits.
Printed Patient Name (if Minor, Parent/Guardian Name) Signature Date I understand responsibility for payment for Dental Services provided in this office for myself and my dependents is mine, due and payable at the time services are rendered unless other financial arrangements have been made with this office. Are other members of your family patient’s at this office? Yes No If so, please list their names So that we may thank them, who referred you to our office? Person to contact in case of emergency Relationship Phone Address (If different from patient) City State Zip I understand that the information given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services with my informed consent that I may need during diagnosis and treatment. Patient/Parent/Guardian Signature Date Although dental personnel primarily treat the area in an d around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important ati o nship with the dentistry you wil receive. Thank you for answering the fol owing questions. Are you under a physicians care now? 0 Yes 0 No If yes, please explain________________________________ Have you ever been hospitalized or had major surgery? 0 Yes 0 No If yes, please explain ________________________________ Have you had a serious head or neck injury? 0 Yes 0 No If yes, please explain ________________________________ Are you taking any medications, pills or drugs? 0 Yes 0 No If yes, please explain ________________________________ Do you take or have you taken Phen-Fen or Redux? 0 Yes 0 No _________________________________________________ Have you taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Pregnant / trying to get pregnant? 0 Yes 0 No Taking Oral Contraceptives? 0 Yes 0 No Nursing 0 Yes 0 No Are you al ergic to any of the fol owing? □ Aspirin □ Penicillin □ Codeine □ Local Anesthetics □ Acrylic □ Metal □ Latex □ Sulfa Drugs □ Other If yes, please explain ________________________________________________________________________________ Please √ if you have or have had any of the following:□ AIDS/HIV Positive Have you had any serious il ness not listed above? 0 Yes 0 No _________________________ Comments: _____________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. The date you last visited a dentist: Last dental cleaning: How often do you normally have dental check-ups and cleanings? Name Phone Address City State Zip Please tell us why you are changing dentists: lease √ if you have had or have each of the fol owing: Have bad tastes or mouth odor frequently? Frequently get cold sores, blisters or other oral lesions? Have any loose teeth or changes in your bite? Frequently get food caught between your teeth? Where? Have parents who have experienced gum disease or Clinch or grind teeth while awake or asleep? Orthodontic treatment (braces / removable appliances)? Hold objects with your teeth (pencils, pens, nails)? Please √ Yes or No
the last 6 months have you experienced: Are you nervous about having dental treatment? Have you ever had an upsetting dental visit? Difficulty in opening or closing your mouth? Difficulty chewing on either side of your mouth? Yes No (if so, please describe) _____________ _____________________________________________ Are you happy with your smile? Yes No, if you could change anything, what would it be? Have you ever considered whitening your teeth? Yes No Are you interested in cosmetic fillings in place of dark fillings? Yes No Have you ever considered straightening your teeth? Yes No Is it important to you to keep all your teeth? Yes No The information on this form is true to the best of my knowledge. If further inf ormation is needed I give this office permission to contact the respective health care providers to release such infor mation. I hereby authorize the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of my dental needs. I also
authorize the Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I further
authorize and consent that the Doctor choose and employ such assistance deemed fit. I understand it is my responsibility to
notify the doctor of any changes in my health or medication on an ongoing basis.

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