Veronafamilydental.net

Patient Information
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as thoroughly as you can.
If you have questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
PATIENT INFORMATION
Date
Please provide your E-Mail address if you wish to receive information from us about future promotions, newsletters, education materials, etc.: Patient’s E-mail Address Married Widowed Single Separated Divorced Partnered for In case of emergency, who should be notified ? Please provide the name of any person or persons you wish to grant permission to Tioga Dental Associates the ability to discuss personal, insurance, financial or dental treatment plan information with (i.e., spouse, parent, guardian, other relative, etc.) PRIMARY DENTAL INSURANCE
INSURANCE AUTHORIZATION
I certify that I, and/or my dependent(s), have insurance coverage with Tioga Dental Associates all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize use of my signature on all insurance submissions. Tioga Dental Associates may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative PAYMENT IS DUE IN FULL AT TIME OF TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED
ADDITIONAL INSURANCE (MEDICAL OR DENTAL)
Person Responsible for Account:
Please complete other side
DENTAL HISTORY
Check (√ ) If you have had problems with any of the following: Bad Breath Bleeding gums Clicking or popping jaw Food collection between teeth Grinding teeth Loose teeth or broken fillings Periodontal treatment Sensitivity to cold Sensitivity to hot Sensitivity to sweets Sensitivity when biting Sores or growths in your mouth MEDICAL HISTORY
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These includes combinations of Lonimin, Adipex, Fastin (brand names of phentermine). Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes NoDo you currently (or have you in the past) taken any Bisphosphonates (e.g. Boniva, Fosamax, Actonel)? Yes NoHave you had any serious illnesses or operations? Yes No If yes, describe Have you ever had a blood transfusion? Yes No If yes, give approximate dates (Women) Are you pregnant? Yes No • Nursing? Yes No • Taking birth control? Yes No Check (√ ) If you have had problems with any of the following: List Medications you are currently taking below: MEDICAL HISTORY FORM AUTHORIZATION
Please provide your signature below to indicate you have completed this medical history form to the best of your knowledge and ability and have provided to TIOGA DENTAL ASSOCIATES accurate and thorough information regarding your medical history and contact information. We are required to ask you to update this form once every 12 months: Signature of Patient, Parent, Guardian or Personal Representative

Source: http://www.veronafamilydental.net/docs/Patient%20Medical%20Info%20Form.pdf