The Dentist of Summerlin Patient Information George A. Davis Jr., D.D.S. Date:_______________ Name __ Preferred Name Last First Middle Initial Social Security Number______________________________ Cell Phone ( ) Would you like a reminder text? YES or NO Home Phone ( ) Work Phone ( ) E-Mail________________________________________ Would you like reminder emails? YES or NO What is the best way to contact you? Please circle all that apply: HOME WORK CELL TEXT EMAIL Address Minor Single Married Separated City State Zip Divorced Widowed Partnered for years Sex M F Age Birth Date Patient Employer/School Occupation Whom may we thank for referring you? In case of an emergency who should be notified? Phone ( ) Dental Insurance Please present insurance card for verification Primary Insurance Information Policy Holder’s name Relation to Patient Birth Date Social Security OR member ID # Address (If different than patient’s) Employer Plan or Group# Dental Insurance Company Name: Address: Phone #: Insurance Authorization I certify that I, and/or my dependent (s) assign all insurance benefits, if any, directly to Dr. George Davis, 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 the use of my signature on all insurance submissions. Print name of Patient, Parent or Guardian Date Signature of Patient, Parent or Guardian Notice of Privacy Practices I acknowledge that I have reviewed the notice of privacy practices from George A. Davis, Jr. DDS and I authorize the use of my health information to carry out treatment, payment activities, and health care operations. Name _________________________Signature ______________________________Date___________________
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The Dentist of Summerlin...The Dentist of Summerlin Patient Information George A. Davis Jr., D.D.S. Date:_____ Name __ Preferred Name Last First Middle Initial 1930 Village Center
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The Dentist of Summerlin
Patient Information
George A. Davis Jr., D.D.S.
Date:_______________ Name __ Preferred Name
Last First Middle Initial
Social Security Number______________________________
Cell Phone ( ) Would you like a reminder text? YES or NO
Home Phone ( ) Work Phone ( )
E-Mail________________________________________ Would you like reminder emails? YES or NO
What is the best way to contact you? Please circle all that apply: HOME WORK CELL TEXT EMAIL
Address Minor Single Married Separated
City State Zip Divorced Widowed Partnered for years
Sex M F Age Birth Date
Patient Employer/School Occupation
Whom may we thank for referring you?
In case of an emergency who should be notified? Phone ( )
Dental Insurance
Please present insurance card for verification
Primary Insurance Information Policy Holder’s name Relation to Patient
Birth Date Social Security OR member ID #
Address (If different than patient’s)
Employer Plan or Group#
Dental Insurance Company Name:
Address: Phone #:
Insurance Authorization I certify that I, and/or my dependent(s) assign all insurance benefits, if any, directly to
Dr. George Davis, 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 the use of my signature on all insurance submissions.
Print name of Patient, Parent or Guardian Date
Signature of Patient, Parent or Guardian
Notice of Privacy Practices
I acknowledge that I have reviewed the notice of privacy practices from George A. Davis, Jr. DDS and I authorize
the use of my health information to carry out treatment, payment activities, and health care operations.
Name _________________________Signature ______________________________Date___________________
HAVE EVER HAD ANY SERIOUS ILLNESS NOT LISTED ABOVE? YES NO
If yes, please explain:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
Signature of Patient, Parent or Guardian: Date:
Medical History Although dental personnel primarily treat the area around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Name: Phone: Date of last medical exam:
What was the exam for? Current Physician:
Have you ever been hospitalized or had a major operation? Are you under the care of a physician? Have you ever had a serious head or neck injury? Are you taking any medications or supplements? If yes please list, the dose and how often: (use back of paper if needed)
Do you take or have you taken Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use Tobacco? Do you use controlled substances?
Women Y N Are you pregnant or trying to get pregnant? Are you taking contraceptives? Are you nursing?
Are you allergic to any of the following?
Aspirin Penicillin Local Anesthetics Acrylic Codeine Metal Latex Sulfa Drugs Other
Y N
Acid Reflux AIDS\HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina Arthritis\Gout Artificial Heart Valve Artificial Joint: What Joint? When? Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Type? Chemotherapy When? Chest Pains Cold Sores\Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Dry Mouth Easily Winded Emphysema
Epilepsy\Seizures Excessive Bleeding Excessive Thirst Fainting Spells\Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack\Failure Heart Murmur Heart Pace Maker Heart Trouble\Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Inflammatory disease Type? Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease
Mitral Value Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments When? Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Sleep Apnea Did you wear a c-pap? Y N Spina Bifida Stomach\Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice
HAVEHAVE
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CHECK ALL THAT APPLY: FAMILY HISTORY UNKNOWN? YES NO
1930 Village Center Circle Suite #12 Las Vegas, NV 89134