Insurance Information
Name of Insured_________________________________________________________________			Relationship to Patient________________
Birthdate______________________	Social Security__________________	Date Employed_______________
Name of Employer______________	Union or Local #___________	Work Phone_____________
Address of Employer____________	City_____________________	State/Prov.______________	ZIP/Post. Code_______
Insurance Company_____________	Group #__________________	Policy/ID #______________
Ins. Co. Address_______________	City______________________	State/Prov.______________	ZIP/Post. Code_______
How Much is your Deductible?___________________	How Much Have You Used?____________________	Max. Annual Benefit_________________
DO YOU HAVE ANY ADDITIONAL INSURANCE? Yes No		IF YES, COMPLETE THE FOLLOWING:
Name of Insured_________________________________________________________________			Relationship to Patient________________
Birthdate______________________	Social Security__________________	Date Employed_______________
Name of Employer______________	Union or Local #___________	Work Phone_____________
Address of Employer____________	City_____________________	State/Prov.______________	ZIP/Post. Code_______
Insurance Company_____________	Group #__________________	Policy/ID #______________
Ins. Co. Address_______________	City______________________	State/Prov.______________	ZIP/Post. Code_______
How Much is your Deductible?___________________	How Much Have You Used?____________________	Max. Annual Benefit_________________

 

			Yes	No
1.	Do your gums bleed while brushing or flossing?
2.	Are your teeth sensitive to hot or cold liquids/foods?
3.	Are your teeth sensitive to sweet or sour liquids/foods?
4.	Do you feel pain to any of your teeth?
5.	Do you have any sores or lumps in or near your mouth?
6.	Have you had any head, neck or jaw injuries?
7.	Have you ever experienced any of the following problems in your jaw?
		Clicking?
		Pain (joint, ear, side of face)?
		Difficulty in opening or closing?
		Difficulty in chewing?
8.	Do you have frequent headaches?
9.	Do you clench or grind your teeth?
10.	Do you bite your lips or cheeks frequently?
11.	Have you ever had any difficult extractions in the past?
12.	Have you ever had any prolonged bleeding following extractions?
13.	Have you had any orthodontic treatment?
14.	Do you wear dentures or partials?
15.	Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
16.	Do you like your smile?

 

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

X____________________________________________________ Signature of patient (or parent if minor)

Doctor's Comments __________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Signature________________________________________________________________________	Date______________________________________