Welcome to our practice! - Bryan Dental Associatesbryandentalssi.com/wp-content/uploads/2015/12/Patient... · 2015-12-16 · Welcome to our practice! Please complete the following

Welcome toour practice!

Please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health or medications, please tell us. If you have any questions, do not hesitate to ask.

PATIENT INFORMATION

Today’s Date:______________________

Patient Name: _________________________________________ Sex: ______ Date of Birth: ___________ Age: ______

Home Address: ________________________________ City: ________________________ State: _____ Zip: ________

Billing Address (if different): _____________________ City: ________________________ State: _____ Zip: _________

Home Phone: ____________________ Cell: _____________________ Email: _________________________________

How do you prefer to be contacted? ____________________________________________________________________

Drivers License #: ______________________________ State: _____ SS#: ______________________________________

Employer/Occupation: __________________________________________________ Bus. Phone: __________________

Spouses Name & Phone #: ____________________________________________________________________________

In the event of an emergency, is there someone you prefer we contact? _______________________________________

Name: ___________________________________________________________ Relationship: _________________

Work #: __________________________Cell #: _______________________ Home #: _________________________

Whom may we thank for referring you? _________________________________________________________________

Insurance Company Name: ___________________________________________________________________________

Insurance Company Address: _____________________________________________ Phone #:____________________

Group #:________________Insured’s Name: _____________________________________________________________

Relationship:_______________________Insured’s Birthdate:_____________ Insured’s SS#: _______________________

Insured’s Employer: _________________________________________________________________________________

Insurance Company Name: ___________________________________________________________________________

Insurance Company Address: _____________________________________________ Phone #:____________________

Group #:________________Insured’s Name: _____________________________________________________________

Relationship:_______________________Insured’s Birthdate:_____________ Insured’s SS#: _______________________

Insured’s Employer: _________________________________________________________________________________

PRIMARY INSURANCE

SECONDARY INSURANCE

Please see next page

Name of your medical doctor: _________________________________ Date of last visit to medical doctor: __________

Name of your last dentist: ____________________________________ Date of last visit to dentist: _________________

MEDICAL HISTORY

Yes NoHeart Problems .......................................................... Chest pain .............................................................. Shortness of breath ............................................ Blood pressure problem ................................... Heart murmur ....................................................... Heart valve problem ........................................... Taking heart medication ................................... Rheumatic fever ................................................... Pacemaker .............................................................. Artificial heart valve ............................................

Blood Problems ......................................................... Easy bruising ......................................................... Frequent nosebleeds ......................................... Abnormal bleeding............................................. Blood disease (anemia) ..................................... Ever require a blood transfusion? ..................

Allergy Problems ....................................................... Hay fever ................................................................. Sinus problems ..................................................... Skin rashes ............................................................. Taking allergy medication ................................ Asthma ....................................................................

Intestinal Problems .................................................. Ulcers ....................................................................... Weight gain or loss ............................................. Special diet ............................................................ Constipation/Diarrhea ....................................... Kidney or bladder problems ............................

Bone or Joint Problems .......................................... Arthritis ................................................................... Back or neck pain................................................. Joint replacement ............................................... (e.g., total hip, pins or implants)

Yes No

Fainting spells, seizures or epilepsy ......................

Stroke(s) ..........................................................................

Frequent or severe headaches ...............................

Thyroid problems ........................................................

Persistent cough or swollen glands ......................

Premedications required by physician ................

Cancer/Tumor ...............................................................

Diabetes .......................................................................... Urinate more than 6 times a day.................... Thirsty or mouth is dry much of the time ... Abnormal bleeding.............................................

Tuberculosis or other respiratory disease...........

Do you drink alcohol? ................................................ Drinks per week? _____________________

Do you smoke? ............................................................. Packs per week? ______________________

Hepatitis, jaundice or liver trouble ........................

Herpes or other STD ...................................................

HIV-positive/AIDS ........................................................

Glaucoma .......................................................................

Do you wear contact lenses?...................................

History of head injury? ..............................................

Epilepsy or other neurological disease?..............

History of alcohol or drug abuse? .........................

Do you have any disease condition, or problem not listed previously that you feel we should know about? ................................................................. If so, please describe: __________________ ___________________________________ ___________________________________

Yes No

Antibiotics or sulfa drugs..........................................

Anticoagulants (e.g. Coumadin) ............................

High blood pressure medicine ...............................

Tranquilizers ..................................................................

Insulin, Orinase, or similar drug..............................

Aspirin .............................................................................

Digitalis or drugs for heart trouble .......................

Nitroglycerin .................................................................

Cortisone (steroids) ....................................................

Natural remedies .........................................................

Nonprescription drug/supplements ....................

Yes No

Are you taking any prescription/over the counter drugs? .............................................................

If so, list each one (name, dosage, amount per day)

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

MEDICAL HISTORY (CONTINUED)

During the past 12 months, have you taken any of the following?

Yes No

Local anesthetics (“Novocaine”) .............................

Penicillin or other antibiotics ..................................

Sulfa drugs .....................................................................

Barbiturates, sedatives, or sleeping pills .............

Aspirin, Acetaminophen, or Ibuprofen ................

Codeine, Demerol, or other narcotics ..................

Yes No

Reaction to metals ......................................................

Latex or rubber dam ...................................................

List any other allergies here:

______________________________________________

______________________________________________

______________________________________________

Are you allergic, or have you reacted adversely, to any of the following?

Yes No

Are you taking contraceptives or other hormones? .........................................................

Are you pregnant? ...................................................... If so, expected delivery date:__________________

Yes No

Are you nursing? ..........................................................

Have you reached menopause? ............................. If so, do you have any symptoms?______________ __________________________________________

Women

Please complete dental history on next page

Yes NoAre you apprehensive about dental treatment?........................................................

Have you had problems with previous dental treatment?........................................................

Do you gag easily? ......................................................

Do you wear dentures? .............................................

Does food catch between your teeth? ................

Do you have difficulty chewing food? .................

Do you chew on only one side of your mouth? .............................................................

Do you avoid brushing part of your mouth because of pain? ...........................................

Do your gums bleed easily?.....................................

Do your gums bleed when you floss? ..................

Do your gums feel swollen or tender? .................

Have you noticed slow-healing sores in or around your mouth? ........................................

Are your teeth sensitive ............................................

Do you feel spurts of pain when your teeth come in contact with:

Hot foods or liquids ............................................ Cold foods or liquids .......................................... Sours? ...................................................................... Sweets? ...................................................................

Do you take fluoride supplements? .....................

Are you dissatisfied with the appearance of your teeth? ................................................................

Do you prefer to save your teeth? .........................

Does your jaw make noise? .....................................

Yes NoDo you clench or grind your jaws frequently? .....................................................................

Do your jaws ever feel tired? ...................................

Does your jaw get stuck so that you can’t open it freely?.....................................................

Does it hurt when you chew or open wide to take a bite? .....................................................

Do you have earaches / pain in front of your ears? .......................................................

Do you have any jaw symptoms or headaches upon awakening in the morning? .........................

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? .......................................................

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? ....................................

Do you have a temporomandibular (jaw) disorder (TMJ)? .............................................................

Do you have pain in the face, cheeks, jaws, joints, throat or temples? ..........................................

Are you unable to open your mouth wide? .......

Are you aware of an uncomfortable bite? ..........

Have you had a blow to the jaw (trauma)? ........

Type of toothbrush bristles? Hard Medium Soft

How often do you brush? ________________________

How often do you floss? _________________________

When was your last dental visit? __________________

DENTAL HISTORY

Please answer the questions below:

AUTHORIZATIONI certify that I, and/or my dependent(s), have insurance with __________________________________________________and assign directly to Name of Insurance Company(ies)Dr. ___________________________ all insurance benefits, if any, 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.

The above named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when current treatment plan is completed or one year from the date signed below.

___________________________________________________________________________________________________ _______________________________Signature of Patient, Parent or Guardian or Personal Representative Date

___________________________________________________________________________________________________ _______________________________Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient

Payment is due in full at time of treatment unless prior arrangements have been approved.

Thomas E Bryan, DMD Thomas J Sayer, DDS, PC

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Plantation!Village!300!Main!Street,!Suite!102!

St!Simons!Island,!Georgia!31522!Phone!(912)!638A9946!

!!

AUTHORIZATION!FOR!SERVICES!The!signature!below!serves!as!authorization!for!services!rendered!by!Dr!Thomas!E!Bryan!and!Dr!Thomas!J!Sayer!for!the!below!named!patient,!and!for!release!of!information!necessary!to!file!insurance!and!assign!benefits!otherwise!payable!to!the!policy!holder,!to!the!doctor.!A!copy!of!the!signature!is!as!valid!as!a!copy.!!!PAYMENT!POLICIES!We!need!your!assistance!and!understanding!of!our!payment!policy.!As!a!courtesy!to!you,!we!will!bill!your!dental!insurance.!However,!you!are!responsible!for!any!nonAcovered!or!unpaid!balances!and!any!preAauthorization!that!your!insurance!company!may!require.!All!services!filed!with!your!insurance!carrier!providing!you!present!all!necessary!information!to!our!office.!!Your%insurance%coverage%is%a%contract%between%you%and%your%insurance%company.!We!accept!cash,!Visa,!Discover,!MasterCard!and!CareCredit.!All%deductibles%are%expected%the%day%services%are%rendered.%%%CANCELLATION!AND!NO!SHOW!POLICY!In!order!to!be!respectful!to!the!needs!of!all!our!patients,!please!be!courteous!and!call!our!office!promptly!if!you!are!unable!to!keep!your!appointment.!This!appointment!time!will!be!given!to!someone!who!is!in!need!of!treatment.!If!you!fail!to!show!up!at!the!scheduled!time!of!your!appointment!it!will!be!recorded!in!your!chart!as!a!“no!show”.!Habitual%no%shows%or%cancellations%less%than%24%hours%prior%to%the%appointment%or%consistency%of%being%later%than%10%minutes%to%your%scheduled%appointment%will%result%in%a%charge%of%$25.00%%By!signing!this!form,!I!have!read!and!understand!all!of!the!above!and!agree!to!Dr!Thomas!Bryan!and!Dr!Thomas!Sayer’s!policies!and!practices.!!!Date!____________________!!! Print!Name!________________________________!!!Signature!_______________________________________!

Thomas E Bryan, DMD Thomas J Sayer, DDS, PC

!

Plantation!Village!300!Main!Street,!Suite!102!

St!Simons!Island,!Georgia!31522!Phone!(912)!638A9946!

!!

Dear!Patient:!!!In!an!effort!to!provide!you!with!flexible!payment!arrangements,!we!have!expanded!our!payment!policy.!!!

PAYMENT!ARRANGEMENTS!ARE!REQUESTED!AT!THE!TIME!OF!YOUR!VISIT!!We!now!offer!the!following!payment!options:!!! !! ____!Payment!by!cash!!! ____!Payment!by!check!!! ____!Payment!by!credit!card!!! ____!Automatic!monthly!billing!your!Visa!or!MasterCard!!! ____!Guarantee!any!amount!not!covered!by!insurance!with!Visa!or!MasterCard!!! ____!PreAtreatment!payments!on!treatment!plan!!Please!make!your!choice(s),!sign!below!and!return!to!office!manager!before!treatment.!!!Our!office!is!full!approved!and!accredited!user!of!the!Visa!and!MasterCard!Health!Care!program!wich!will!enable!you!to!use!your!Visa!and!MasterCard!to!automatically!cover!amounts!not!paid!by!your!insurance.!You!may!also!choose!a!comfortable!amount!to!be!automatically!billed!to!your!Visa!or!MasterCard!on!a!monthly!basis.!!!If!none!of!the!above!apply,!please!see!the!office!manager.!Thank!you.!!!____________________________________!Print!your!name!here!and!sign!below!!!____________________________________!!! Date:!________________________!