MINOR PATIENT INFORMATION RECORD

PATIENT INFORMATION RECORD
The following information is needed for our records. Please print answers to all questions
Patient’s Name
First
Middle Int
Last
Age
Birth Date

MonthDayYear
Date
Marital Status
Social Security No.
Home Phone
Home Address
City/State
Zip
Cell Phone
Email Address
example@example.com
Patient Employer
Business Phone
Employer Address
City/State
Zip
Name of Spouse or Guardian
Birth Date
Spouse's Employer
Business Phone
Address

Employer Address

Street Address Line 2

CityState / Province

Zip
City/State
Social Security No.
Home Phone
INSURANCE INFORMATION
Dental Insurance Company
ID #
Group #
Mailing Address
Name of Subscriber (self, spouse, or patient)
Referred by
Physician's Name
Pharmacy Name & #
Physician's Address
Payment Policy
Every effort is being made to keep down the cost of dental care. You can help by paying at the time of your visit. We accept credit cards, personal checks, and cash. If treatment will require several visits, you will be given an estimated cost per visit and asked to make definite financial arrangements with a member of our business office staff.
Dental Insurance
Each patient is financially responsible for his or her own account. We are happy to cooperate with any patient whose treatment is covered by dental insurance. The fees we charge for services rendered to those who are insured are our usual customary fees charged to all patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage offered. There is a waiting period of 30 to 90 days for the insurance claim to be processed and payment made to us. Due to the waiting period, we request financial arrangements be made at the start of treatment. When insurance payment is received, we will refund any overpayment or request that you pay any remaining balance.
Signature

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Date

MonthDayYear
Date
FINANCIAL POLICY
AS A COURTESY TO YOU, WE WILL GLADLY FILE YOUR INSURANCE CLAIMS; however, it is your responsibility to handle any problems with your insurance company. We will be happy to re-file any claims that you request after you have contacted your insurance company to verify that re-filing is necessary.WE ARE A PPO PROVIDER TO BLUE CROSS BLUE SHIELD OF ALABAMA AND DELTA DENTAL PREMIER ONLY; it is your responsibility to know what this means to you regarding your insurance benefits. Some insurance companies will send the checks to the patients. If you have a one of these contracts, payment is due in full at the time services are rendered.YOU ARE RESPONSIBLE FOR ANY DEDUCTIBLE OR CO-PAYMENT AT THE TIME OF SERVICE. We will not bill you for this amount.OUR FEES ARE NOT DETERMINED BY INSURANCE COMPANIES. Oftentimes, our fees are lower than the allowable charge for your insurance plan; however, if our fees are greater than their allowable charge, you are responsible for the difference.We will try to help you understand your dental insurance and receive the maximum benefit from it; however, WE CANNOT GUARANTEE ANYTHING ABOUT YOUR INSURANCE as your contract is with the insurance company and not with this office. All payment decisions are made by the insurance company upon their receipt of claim; we can only estimate your benefits. It is your responsibility to know your insurance coverage.
ANY BALANCE NOT PAID BY YOUR INSURANCE COMPANY AFTER 60 DAYS IS YOUR RESPONSIBILITY. If your balance is not paid by the due date on the invoice, a late payment fee of $5.00 will be added to your account.I UNDERSTAND & AUTHORIZE all dishonored checks plus a processing fee to be electronically debited from my account.ANY BALANCES OVER 90 DAYS WILL BE SENT TO A COLLECTION AGENCY, unless other arrangements were made ahead of time with this office. The patient understands that these services are their responsibility, regardless of insurance payment. The patient further agrees to pay nominal charges for all services and products rendered, to waive any right of notice or exemption in the state of Alabama or any other state with regard to personal property, to add one and half (1 1⁄2 % ) per month to any balanced owed, in the event or default to also pay reasonable collection charges, attorney fees and court costs.
REIMBURSEMENT PLANS ONLY: if your insurance coverage is through a reimbursement plan, you will be required to pay for services at the time of your visit; you will be given a receipt and an insurance claim form to be used when you file for reimbursement. No receipts will be given until charges are paid in full.
I HAVE READ AND UNDERSTOOD THE ABOVE STATED POLICY IN ITS ENTIRITY AND AGREE TO ADHERE TO ITS CONDITIONS.
PATIENT'S NAME (please print)
Date

MonthDayYear
Date
PATIENT'S SIGNATURE

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Date
(Parent or guardian if patient is a minor)
Name
Date

MonthDayYear
Date
Have you had any serious illnesses?
Have you lost time from work at any time because of serious illness?
Are you under care of a physician at present?
Are you taking any medicines now or in the past year?
If so, please list medication and reason for taking it:
Are you allergic or have you had a reaction to:

Local anestheticsPenicillin or other antibioticsSulfa drugsBarbiturates, sedatives, or sleeping pillsCodeine or other narcoticsAspirinIodineLatexTetracyclineOther
Are you taking any blood thinner medications (aspirin, Plavix, Coumadin, Warfarin)
Are you taking any bone sparing medications (Boniva, Fosamax)
Have you ever had complications from taking local anesthesia?
Have you ever had any operations? If so, please list
Have you ever had a blood transfusion?
11. Do you presently wear contact lenses?
Heart Failure

Heart FailureEmphysemaAIDS/HIVHeart Disease of AttackChronic BronchitisHepatitis A (infectious)Angina PectorisCoughHepatitis B (serum)High Blood PressureTuberculosis (TB)Liver DiseaseHeart MurmurAsthmaYellow JaundiceRheumatic FeverHay FeverBlood TransfusionConginital Heart LesionsSinus TroubleDrug or Alcohol AbuseScarlet FeverAllergies or HivesHemophiliaArtificial Heart ValveDiabetes (type 1 or 2)Venereal Disease (Syphilis, Gonorrhea)Mitral Valve ProlapseThyroid DiseaseGenital HerpesHeart PacemakerX ray or Cobalt TreatmentCold SoresHeart SurgeryChemotherapy (Cancer, Leukemia)Epilepsy or SeizuresArtificial JointArthritisFainting or Dizzy SpellsAnemiaOsteoporosisNervousnessStrokeRheumatismPsychiatric TreatmentKidney TroubleCortisone MedicineSickle Cell DiseaseUlcersGlaucomaBruise Easily
13. Do you have any disease, condition or problem not listed?
Are you pregnant now?
Are you practicing birth control?
Do you anticipate becoming pregnant?
To the best of m knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fail.
Signature

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Date

MonthDayYear
Date
Name:
Date:

MonthDayYear
Date
Dental History
When were your teeth last "cleaned"?
By Whom?
2. How frequently is this usually done?
Have you had previous "gum trouble" (Pyorrhea, trench mouth, etc) and/or previous gum treatment including cleanings?
If so, specify:
4. Have you been told what causes dental and gum diseases?
5. Have you ever been shown how to brush your teeth?
By whom
How many times a day do you brush your teeth?
Type of Brush

ManualElectricHardMediumSoft
Brand Name
How Often Do You Replace Your Brush
Additional Oral Hygiene Aides

Tooth PicksDental FlossRubber TipsWater-pikOther
9. Do you use tobacco of any form?
10. How many cigarettes(cigar) do you smoke daily?
Have you ever had orthodontic treatment (teeth straightened)?
By whom?
12. Do you have any fear of having dental treatment done?
Oral Symptoms
Oral Symptoms

Does food catch or wedge between teeth?Do you form "tartar" rapidly?Have teeth that are shiftting positions?Have teeth that are changing color?Have sensitive teeth or roots?Have sore or tender gums>Bleeding gums?Gum abscess(es)?Loose teeth?Unpleasant taste?Unpleasant odor?Receeding gums?Have frequent fever blisters, cold sores, or mouth ulcers?Do you clench or grind your teeth?Do you awaken in the morning with sore jaws?Do you awaken in the morning with a dry mouth or generally breathe through your mouth rather than your nose?
First Name
Middle Int
Last Name
Age
Birth Date
Marital Status
Social Security No.
Home Phone
Home Address
City / State
Zip
Patient Employer
Business Phone
Employer Address
City / State
Zip
Patient's Father
Birth Date
Father's Employer
Business Phone
Address If Different
Email Address
Employer Address
City / State
Zip
Social Security No.
Home Phone
Patient's Mother
Birth Date
Address If Different
Email Address
Mother's Employer
Business Phone
Employer Address
City / State
Zip
Social Security No.
Home Phone
Dental Insurance Company
ID #
Group #
Mailing Address
Name of Subscriber (self or parent)
Referred By
Physician's Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION RECORD

Patient’s Name

INSURANCE INFORMATION

Payment Policy

Dental Insurance

FINANCIAL POLICY

Dental History

Oral Symptoms