Full Legal Name:
What would you prefer to be called:
Best place to contact you:
Same as Patient Information
Relationship to patient:
Driver's License #:
(Please fill out completely and provide copy of insurance card)
Reason for today's visit:
Last dental exam:
Last dental x-rays:
Please indicate any of the following concerns:
Pain, clicking or popping of jaw
Bleeding, swollen gums
Blisters/sores in/around mouth
Name of primary physician:
Have you ever been treated for a serious illness:
If yes please explain:
Have you been diagnosed with any of the following:
Mitral Valve Prolapse
Artificial Heart Valve
Artificial Joint Replacement
High Blood Pressure
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:
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.
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