Michael Page DDS - New Patient Form

 
 

Patient Information

Title:

Full Legal Name:

What would you prefer to be called:

Gender

Birthdate:

SS:

Marital Status:

Spouse's Name:

Address:

Apt/Suite:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Email:

Best place to contact you:

Employer:

Occupation:

Referred by:

 

Person Responsible for Account

 

Same as Patient Information

 

Title:

Full Legal Name:

Relationship to patient:

Birthdate:

SS:

Driver's License #:

Address:

Apt/Suite:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Email:

Best place to contact you:

Employer:

Occupation:

 

Dental Insurance Information

(Please fill out completely and provide copy of insurance card)

Primary Insurance

Insurance Carrier:

Insurance Phone:

Employer:

Employee:

Birthdate:

SS:

Relationship to patient:

 
Secondary Insurance

Insurance Carrier:

Insurance Phone:

Employer:

Employee:

Birthdate:

SS:

Relationship to patient:

 

Emergency Contact Information:

Name:

Relationship to patient:

Home Phone:

Cell Phone:

Work Phone:

 

Dental Information:

Reason for today's visit:

Previous Dentist:

Phone #:

Last dental exam:

Last dental x-rays:

 

Please indicate any of the following concerns:

Pain, clicking or popping of jaw

Grinding teeth

Headaches

Sensitive teeth

Bleeding, swollen gums

Stained teeth

Blisters/sores in/around mouth

Bad breath/taste

Loose/Broken teeth

Lost/Broken filling(s)

Gum Disease

Other

   

Medical Information:

Name of primary physician:

Phone:

Have you ever been treated for a serious illness:

If yes please explain:

 

Have you been diagnosed with any of the following:

Heart Murmur

Diabetes

Pacemaker

Mitral Valve Prolapse

Emphysema

Osteoporosis

Alcohol/Chemical Dependency

Epilepsy

Radiation/Chemotherapy

Arthritis

Heart Condition

Rheumatic Fever

Artificial Heart Valve

Hepatitis

Stroke

Artificial Joint Replacement

High Blood Pressure

Tuberculosis

Asthma

Kidney Disease

Ulcers

Bleeding/Clotting Disorders

Liver Disease

Other

Surgery: Pins, Plates or Rods

 

Please describe any of the above conditions:

Are you being treated for any conditions not listed above:

Please list ALL medications you are currently taking:

 

Are you allergic to, or had an unusual reaction to, any of the following:

Local anaesthetics

Sulfa drugs

Aspirin

Penicillin

Codeine

Latex

Iodine

Fluoride

Talcum

Narcotics

Barbiturates

Antibiotics

Sedatives

Other

 

For women: Are you pregnant?

If yes, what month?

 

 

I understand the above information and guarantee this form was completed to the best of my knowledge and have not made any deliberate omissions. I authorize the staff to perform any necessary services needed during diagnosis and treatment.

I consent to your disclosures of my information, which you deem necessary, in connection with my treatment.

I hereby authorize the use of my signature below on all insurance submissions and authorize the dentist to release all necessary information to secure payment for treatment rendered. I authorize payment of the dental benefits, otherwise payable to me, directly to the office of Dr. Michael Page. I fully understand that I am responsible for all costs of dental treatment whether they are covered by my insurance or not. I understand that if my account balance is not paid within 30 days I will automatically be charged a finance charge of 18% APR (1.5% monthly) unless other written financial arrangements have been made prior to my treatment. I understand that the accompanying parent (or guardian) of a minor will be responsible for full payment.

I acknowledge that the office of Dr. Michael Page does have a Notice of Privacy Practices and I understand that I do have the opportunity to receive and read a copy of the Notice of Privacy Practices.

 

Agree

 

 

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