New Patient Form

New Patient Form

Patient Information

Marital Status:
Sex:

In Case of Emergency: Nearest relative (not living at your address):

IF PATIENT IS A MINOR:

Is the patient covered by Dental Insuance?
If patient is over 19 years of age and covered on parent's policy, are they a full time student?

ASSIGNMENT OF INSURANCE BENEFITS:

In consideration of services rendered, I heareby transfer and assign to CHARLES W. CLINE, D.D.S. all right and title and interest in any payment due me for services as provided in the policy or policies of insurance held by me or on my behalf. I agree TO PAY DR. CHARLES W. CLINE, D.D.S. the charges which exceed the amount paid by the policies held by me. I further agree and authorize the above named clinic to release any information requested by the insurance company (is) or it's representatives. I understand that I will be held responsible for any fees that are not paid by the insurnace compnay.

Medical History

Please answer for the following questions to the best of your ability, realizing that true and sccurate answers are important to the delivery of quality care. All information will be kept confidential.

**PLEASE ANSWER BY CHECKING YES (Y) OF NO (N) FOR EACH INDIVIDUAL QUESTION**

1. How would you describe your general health?
2. Has there been any change in your general health within the past year?
3. Are you currently under a physician's care?
 
4. Date of your last checkup by a physician:

5. Have you had any serious illness, operations, or hospitalizations?
6. Have you ever had any intravenous sedation or general anesthesia?
7. Do you generally tolerate dental treatment well?
 
8. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Heart Disease that was detected at birth: (valve damage, murmur, artifical heart valve)?
B. Have you ever been pre-medicated with antibiotics for dental treatment?
C. Rheumatic Fever or Rheumatic heart disease?
D. Cardiovascular disease (chest pain, heart trouble, heart attack, coronary artery disease, high blood pressure, stroke, palpitations, heart surgery, angioplasty, pacemaker)?
E. Lung disease (asthma, emphysema, chronic cough, bronchitis, pneumonia, TB, shortness of breath)?
F. Neurologic disorders (seizure, epilepsy, fainting, dizziness, nervous disorder)?
G. Blood disease (bleeding disorder, anemia, blood transfusion, do you bruise easliy)?
H. Liver disease (jaundice, hepatitis)?
I. Kidney disease?
J. Thyroid disease (hypothyroidism, tumor)?
K. Diabetes?
If yes Type I or Type II
L. Stomach ulcers or Intestinal problems?
M. Glaucoma?
N. Frequent or recurring mouth sores?
O. Arthritis?
P. Implants/artificial joints anywhere in your body? (heart valve, hop, knee)
Q. Have you ever been diagnosed with cancer?
 
1. Have you received chemotherapy? If yes last treatment

 
2. Have you received radiation therapy? If yes last treatment

R. Sinus or Nasal problems?
S. Any disease, drug or transplant operation that has depressed your immune system?
T. Recurrent infections of any kind?
 
9. ARE YOU TAKING ANY OF THE FOLLOWING:
A. Antibiotics?
B. Anticoagulants (blood thinners)?
C. Thyroid Medication?
D. High blood pressure or heart medicaions?
E. Steroids?
F. Tranquilizers, Antidepressants?
G. Stomach or GI medications (antacids, etc.)?
H. Cholesterol reducint drugs?
I. Aspirin, ibuprofen, NSAIDS, or amt-inflammatory drugs, narcotics, opioids, or other pain relievers?
J. Weight reduction pills or diet aids. (over the counter or "natural products")?
K. Vitamins, Natural remedies (gingko biloba, ephedra, ginseng, etc.)?
L. Marijuana, cocaine or other "recreational" drugs?
M. Any other regular medications, pills, supplements or drugs?
10. Are you taking or have you ever taken any of the following medications? These medicines are used for osteoporosis and cancer chemotherapy treatment.
 
PLEASE LIST ALL CURRENT MEDICATIONS HERE:

 
11. ARE YOU ALLERGIC TO OR HAD A BAD REACTION FROM:
A. Local anesthetic (Novocain-like drugs)?
B. Penicillin, Amoxicillin, Cephalosoris?
C. Other Antibiotics?
D. Barbiturates, seditives?
E. Aspirin, ibuprofen, NSAIDS, or other pain medicines?
F. Codeine or narcotics or opioids?
G. Latex?
H. Other allergies or reactions?
12. Do you have hay fever, frequent skin rashes, etc...:
13. Do you use alcohol?
14. Do you smoke?
15. Do you use spit or chewing tobacco?
16. Are you, or have you been, in a drug or alcohol recovery program?
17. Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
 
Please Explain?

18. Do you wish to talk to the doctor privately about anything?
19. Any additional comments?
 
20. WOMEN
A. Are you taking birth control pills?
B. Are you pregnany, trying to become pregnant or is there, any chance you might be pregnant?
C. Are you breast feeding?
D. Are you taking hormonal replacement?

I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY AND REALIZE THAT INCOMPLETE INFORMATION MAY HAVE AN ADVERSE EFFECT ON MY TREATMENT. TO THE BEST OF MY KNOWLEDGE, THE INFORMATION ABOVE IS COMPLETE AND ACCURATE

Dental History

 
1. What is your chief dental problem?

2. Have you ever had a local anesthetic ("Novacain") for dental purposes?
3. Have you ever had any reactions to a dental injection?
4. Have you had any difficulty with any denal treatment in the past?
5. Have you had any prolonged bleeding with extractions in the past?
6. Do you have any unhealed injuries or sores in or around your mouth?
7. Have you been advised on the care of your teeth and gums?
8. Do your gums bleed while brushing?
9. Do you floss?
10. Have you had any head, neck, or facial pain?
11. Have you had any head or neck injuries such as whiplash?
12. Do you have problems with earaches?
13. Do you have problems with headaches?
14. Do you habitually clech or grind your teeth during the day or night?
15. Do you tend to chew on one side only?
If so, which side?
16. Do you have any popping, clicking or other noises from your jaw joint(s)?

17. How long has it been since your last dental visits?

18. Have you ever had orthodontics (Braces)?
19. Have you ever had Periodontal (Gum) Surgery?
20. Other major dental treatment?
21. Are you unhappy with your smile or any particular aspect of the way your teeth look or feel?
HOW DO YOU FEEL ABOUT LOSING A TOOTH?

I certify that the answers given are correct to the best of my knowledge. Furthermore, I authorize the release of any medical and/or dental information necessary for the completion of my treatment.

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Security Measure

Contact Us

We believe that excellent care begins with open communication. If you need more information, have any questions, or want to schedule an appointment, please contact us!