1 PATI E NT I N FO RMATION 2 I N S U RANCE I N FO RMATION
Patient Name:
Last First MI
Date: Male Female Married Single ChildBirth Date: Home #: Work #:
Email Address: Address: Street Apt. #
City ZIP Code
RESPONSIBLE PARTY INFORMATION
same as above Name:
Last First MI
Male Female Married SingleBirth Date:
EMPLOYMENT INFORMATION
The following is for: the patient the person responsible for paymentEmployer Name: Occupation:
Cell #: Best time to call:
Preferred Name:
Home #: Work #:
Address: Street Apt. #
City ZIP Code
Cell #: Best time to call:
Address: Street Apt. #
City ZIP Code
Subscriber’s Name:
Subscriber’s Birth Date: Relationship to Patient: Insurance Company Name:
Group #: Is there any additional dental insurance? Yes No
ASSIGNMENT and RELEASE
xPatient or Responsible Party Signature Date
REFERRAL INFORMATION
Passing By Newspaper Relative Another Patient Direct Mail Work Friend Insurance Plan Guide Other
Name of Person Referring you to us:
Dental insurance is a contract between the patient and the insurance carrier and not between the insurance carrier and PacificSmiles. As a courtesy, PacificSmiles will file the insurance claim on your behalf. In the event that the insurance pays less than the actual bill for services, the patient is responsible to pay any co-payments, deductibles or unpaid balances.
Subscriber’s SS# or ID#:
Insurance Phone #:
Subscriber’s Name:
Subscriber’s Birth Date: Relationship to Patient: Insurance Company Name:
Group #:
Subscriber’s SS# or ID#:
Insurance Phone #:
Whom may we thank for referring you to Pacific Smiles?
3 I N C A S E OF E M E RG E NCY
Home #:
Name:
Relationship: Cell #:
Work #: Ext.
4 DE NTAL I NTE RVI EW
Name of Previous Dentist and Location:
How long has it been since your last thorough exam?
How long has it been since your last complete series/full mouth x-rays of your teeth?
What prompted you to seek dental care at this time?
Yes No
Yes No If yes, describe:
Are you fearful? Yes No Rate your fear level (1-10):
Did you ever have any bad experiences or reason for the fear? (Explain):
Yes No
Yes No
Special time frames?
What quality of dentistry do you want us to recommend? “Just Patch It” Average Ideal/The Best
Place a mark on “yes” or “no” to indicate if you have had any of the following: Yes No Clenching Teeth
Clicking or Popping Jaw Joints
Fingernail Biting
Grinding Teeth
Headaches
Jaw Pain or Tiredness
Lip or Cheek Biting
Orthodontic Treatment
Pain Around Ear
Ringing in the Ears
Sensitivity to Biting
Sensitivity to Hot, Cold, Sweets
Vertigo
Yes No
Do you have an unpleasant taste or odor in your mouth?
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Gums Swollen or Tender
Periodontal Treatment / Gum Treatment
Chew on One Side of Mouth
Loose Teeth
Broken Fillings
Sores or Growths in Your Mouth
Do you feel pain to any of your teeth?
Ear Congestion/”Blocked Feeling” in Ears
If any of your mercury/silver fillings need replacementwould you prefer to have a more natural tooth-colored restoration instead?
Are you dissatisfied with the way your teeth look? (For example: color, shape, spaces, etc.)
Do you know we provide in-office financing?
Did you have any finance concerns?
If yes, what are your financial concerns?
Do your gums bleed while brushing or flossing?
Have you had a bite plate or night guard made?
Yes No Are you missing any teeth?If yes, would you like options to replace them? Yes No
5 H EALTH H ISTO RYPhysician’s Name:
Date of Last Visit:
Aids/HIV ANEMIAArthritis, Rheumatism
AsthmaBack ProblemsBleeding abnormally, with... extractions or surgeryBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough, persistent or bloody
*DiabetesEmphysemaEpilepsy
Do you take medication for osteoporosis? (ex. Fosomax)If yes, what and how often?
Do you use antidepressants or sleeping pills? If yes, list name(s)
Have you ever been hospitalized for any surgical operations or serious illness within the last 5 years? If yes, please explain
Are you on any blood thinners, including aspirin? If yes, what?
MEDICATIONSList any medications you are currently taking and the correlating diagnosis:
Pharmacy Name: Phone:
To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicineschange, I shall inform the dentist and the team at the next appointment without fail.
Patient or Responsible Party Signature: x Date:
Fainting or Dizziness*Glaucoma
*Heart MurmurHeart ProblemsHepatitis TypeHerpesHigh Blood PressureJaundiceJaw PainJoint ReplacementKidney DiseaseLiver Disease Low Blood PressureMitral Valve ProlapseNervous Problems
*PacemakerPsychiatric CareRadiation TreatmentRespiratory Disease
Scarlet FeverShortness of Breath
*Sinus TroubleSkin RashSpecial DietStrokeSwollen Feet or AnklesSwollen Neck GlandsThyroid ProblemsTonsillitisTuberculosisTumor or Growth on... Head or NeckUlcerVenereal DiseaseOthers
Comments:
Yes No
Yes No
Yes No
Yes No
WOMENAre you pregnant?If yes, when is your due date? Taking birth control pills?
Are you taking hormones?
ALLERGIES No Allergies Local Anesthetic
Aspirin Penicillin
Barbiturates (sleeping pills) Sulfa
Codeine Latex
Iodine Other
Yes No
*Artificial Heart Valves*Artificial Joints
*Rheumatic Fever
*Osteoporosis
Have you had a history of previous sinus infections orcongestion?
6 CON S E NT AN D R E LEA S E S
Patient or Responsible Party Signature: x Date:
Please INITIAL and SIGN below:
I hereby authorize Dr. Fred Kim and/or his team to take photographs of my face, jaw and teeth. I understand that the photographs will be used as a record of my care and treatment and may be used for educational and marketing purposes.
I must provide with 48 business hours advance notice for any cancellations of any of my appointments in order to avoid the imposition of cancellation fees; which are determined by the length and type of service being rendered at the scheduled visit. Such cancellation fees are non-refundable.
I certify that I have read and understand the above information to the best of my knowledge. The questions on both sides have been accurately answered, and I understand that providing incorrect information can be dangerous to my health.
I understand that dental insurance is a contract between the patient and the insurance carrier and not between the
insurance carrier and PacificSmiles. As a courtesy, PacificSmiles will file the insurance claim on your behalf.
In the event that the insurance pays less than the actual bill for services, the patient is responsible to pay any
co-payments, deductibles or unpaid balances.
I hereby authorize Pacific Smiles and Dr. Kim to administer such medicine and perform such diagnostic andtherapeutic procedures as may be necessary for proper dental care.