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Glenwood Location
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Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Financial & Insurance Information
Online Patient Forms
Privacy Policy
About
About Us
Career Opportunities
Contact
Glenwood Location
Hancock Location
Services
Cosmetic Dentistry
Preventative Dentistry
Restorative Dentistry
Oral Surgery & Prosthetics
Special Services
Orthodontic Treatment
Meet the Team
Patient Resources
Frequently Asked Questions
Financial & Insurance Information
Online Patient Forms
Privacy Policy
About
About Us
Career Opportunities
Contact
Glenwood Location
Hancock Location
Call for appiontment
Call For Appointment
Annual Update Form
Annual Update Form
Step
1
of
5
- Patient/Insurance Information
20%
Patient Information
First Name
*
Required
First
Last Name
*
Required
Last
Phone
*
Required
Email
*
Required
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Marital Status
*
Required
Single
Married
Widowed
Separated
Divorced
Birthdate
*
Required
MM slash DD slash YYYY
Patient Employer
Occupation
Work Phone
How would you like to be notified for upcoming appointments?
Email
Phone
Text
Mobile Carrier (for text message reminder of appointments):
Insurance Information
Any Dental Insurance Coverage?
*
Required
Yes
No
Who is your carrier?
*
Required
Person Responsible for Account
*
Required
Relation to Patient
Birthdate
MM slash DD slash YYYY
Phone
Address (if different from patient's)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please check if you have had any of the following:
Bad breath
Bleeding gums
Clicking or popping jaw
Food collection between teeth
Grinding teeth
Loose teeth or broken fillings
Periodontal Treatment
Sensitivity to hot or cold
Sensitivity to sweets or biting
Sores or growths in your mouth
Frequent headaches
Orthodontic work
Prolonged bleeding following extractions
Pain (joint, ear, side of face)
Other
If you could change something about your smile or teeth, what would it be?
Permission
Emergency Contact
*
Required
Emergency Contact Relation
*
Required
Emergency Contact Phone
*
Required
Patient Medical History
Name of Physician and their specialty:
*
Required
Date of most recent Medical Exam:
MM slash DD slash YYYY
Purpose for medical exam:
*
Required
1. Hospitalization for illness or injury?
*
Required
Yes
No
2. An allergic or bad reaction to any of the following:
*
Required
Aspirin (ibuprofen, acetaminophen, codine)
Penicillin
Erythromycin
Tetracycline
Sulfa
Local anesthetic
Flouride
Chlorhexidine (CHX)
Iodine
Metals (nickle, gold, silver)
Latex
Nuts
Fruit
Milk
Red dye
Other
No Known Allergies
3. Heart problems, or cardiac stent within the last 6 months
*
Required
Yes
No
4. History of infective endocarditis
*
Required
Yes
No
5. Artificial heart valve, repaired heart defect (PFO)
*
Required
Yes
No
6. Pacemaker or implantable defibrillator
*
Required
Yes
No
7. Orthopedic or soft tissure implant (e.g joint replacement, breast implant)
*
Required
Yes
No
8. Heart murmur, rheumatic or scarlet fever
*
Required
Yes
No
9. High or low blood pressure
*
Required
Yes, high blood pressure
Yes, low blood pressure
No
10. A stroke (taking blood thinners)
*
Required
Yes
No
11. Anemia or other blood disorder
*
Required
Yes
No
12. Prolonged bleeding due to a slight cut (or INR > 3.5)
*
Required
Yes
No
13. Pneumonia, emphysema, shortness of breath, sarcoidosis
*
Required
Yes
No
14. Chronic ear infections, tuberculosis, measles, chicken pox
*
Required
Yes
No
15. Breathing problems (e.g asthma, stuffy nose, sinus congestion)
*
Required
Yes
No
16. Sleep problems (e.g sleep apnea, snoring, insomnia, restless sleep, bedwetting)
*
Required
Yes
No
17. Kidney disease
*
Required
Yes
No
18. Liver disease or jaundice
*
Required
Yes
No
19. Vertigo (e.g "the room is spinning")
*
Required
Yes
No
20. Thyroid, parathyroid disease, calcium deficiency
*
Required
Yes
No
21. Hormone dificiency or imbalance (e.g polu cistic ovarian syndrome)
*
Required
Yes
No
22. High cholesterol or taking statin drugs
*
Required
Yes
No
23. Diabetes
*
Required
Yes
No
24. Stomach or deodenal ulcer
*
Required
Yes
No
25. Digestive or eating disorders (e.g ciliac disease, gastric reflux, bulmia, anorexia)
*
Required
Yes
No
26. Osetoporosis/osteopenia or ever taken anti-resorptive medications (bisphosphonatse)
*
Required
Yes
No
27. Arthritis or gout
*
Required
Yes
No
28. Autoimmune disease (e.g rheumatoid arthritis, lupus, scleroderma)
*
Required
Yes
No
29. Glaucoma
*
Required
Yes
No
30. Contact lenses
*
Required
Yes
No
31. Head or neck injuries
*
Required
Yes
No
32. Epilepsy, convulsions (seizures)
*
Required
Yes
No
33. Neurologic disorders (e.g alzheimer's disease, dementia, prion disease)
*
Required
Yes
No
34. Viral infections and cold sores
*
Required
Yes
No
35. Any lumps or swelling in the mouth
*
Required
Yes
No
36. Hives, skin rash, hay fever
*
Required
Yes
No
37. STI/STD/HPV
*
Required
Yes
No
38. Hepatitis
*
Required
Yes
No
39. HIV/AIDS
*
Required
Yes
No
40. Tumor, abnormal growth
*
Required
Yes
No
41. Radiation therapy
*
Required
Yes
No
42. Chemotherapy, immunosuppressive meds
*
Required
Yes
No
43. Emotional difficulties
*
Required
Yes
No
44. Psychiatric treatment or antidepressant medication
*
Required
Yes
No
45. Concentration problems or ADD/ADHD
*
Required
Yes
No
46. Alcohol/Recreational drug use
*
Required
Yes
No
Are you:
47. Presently being treated for any other illness
*
Required
Yes
No
48. Aware of a change in your health in the last 24 hours (fever, chills, new cough, diarrhea)
*
Required
Yes
No
49. Taking medications for weight management
*
Required
Yes
No
50. Taking dietary supplments, vitamins, and/or probiotics
*
Required
Yes
No
51. Often exhausted or fatigued
*
Required
Yes
No
52. Experiencing headaches or chronic pain
*
Required
Yes
No
53. A smoker, smoked previously or other (smokless tobacco, vaping, e-cig, or cannabis)
*
Required
Yes
No
54. Considered a touchy/sensitive person
*
Required
Yes
No
55. Often unhappy or depressed
*
Required
Yes
No
56. Taking birth control pills
*
Required
Yes
No
57. Currently pregnant
*
Required
Yes
No
58. Diagnosed with a prostate disorder
*
Required
Yes
No
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:
List all medications, supplements, vitamins, and/or probiotics you're currently taking:
Authorization
Consent
I agree to the below statement.
I consent to allow photographs and/or x-rays to be used for demonstrations, marketing material, patient education, etc.
Consent
*
Required
I agree to the below statement.
I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions.
Consent
*
Required
I agree to the below statement.
I have answered all questions regarding myself, or my dependent's medical history and present health condition fully and truthfully, including allergies. I also understand if there are any changes in my, or my dependents health I am to inform the doctor at my next appointment.
Consent
*
Required
I agree to the below statement.
I agree to provide a minimum of 24 hour notice if I need to change my appointment for any reason. I understand if I fail an appointment I may be charged a fee. Failure to show for a second appointment may result in dismissal from the practice.
Consent
*
Required
I agree to the below statement.
I instruct the dentist to deliver care that, in their professional judgement, is necessary in the restoration of my health once they've been discovered and discussed.
Consent
*
Required
I agree to the below statement.
State and federal laws require us to maintain the privacy or your health information and to inform you about our privacy practices by providing you with a Notice of Privacy Practices. This form is available online for your convenience, if you prefer a paper copy, please feel free to contact us.
Full Name
*
Required
Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.
Date
*
Required
MM slash DD slash YYYY
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