Expressions Patient Medical Dental Information Form (UPDATED)

New Patient
Occupation / Employer
What school are you attending?
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Home
Please enter a valid phone number.
Work
Please enter a valid phone number.
Cellular/Other
Please enter a valid phone number.
Emergency Contact
Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.

Insurance Policy Information

Please provide us with your Insurance Benefits Card
Do you have insurance?*

YesNo
Please specify*

Primary InsuranceSecondary Insurance
Primary
Would you like to upload / click a picture of the insurance card or enter the details of the card?

Fill the detailsUpload / Click the Picture of Insurance Card
Please click Front and Back of the Insurance Card

Cancelof
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company*
Employer
Policy / Group Number*
Birth Date

MonthDayYear
I.D. / Certificate Number*
Secondary
Would you like to upload / click a picture of the insurance card or enter the details of the card?

Fill the detailsUpload / Click the Picture of Insurance Card
Please click Front and Back of the Insurance Card

Cancelof
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company*
Employer
Policy / Group Number*
Birth Date

MonthDayYear
I.D / Certificate Number*
Patient Consent For Electronic Insurance Claim Submission

Please review the following if you would like our office to process your dental insurance claims electronically.
I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Expressions Dental Hygiene Clinic. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.
Signature of Patient

Clear
Patient's Name

First NameMiddle NameLast Name
Signature Of Responsible Party

Clear
Responsible Party's Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date

	Please list
Medications
Latex/Rubber Products
Other (eg Hayfever, foods)

To the best of my knowledge, I have answered every question truthfully, completely and accurately.*

I Understand
Patient's Signature*

Clear
Patient's Name

PrefixFirst NameMiddle NameLast Name
Responsible Party's Signature*

Clear
Responsible Party's Name

PrefixFirst NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

	Yes	No
Asthma
Heart or blood pressure problems
Replacement or repair of a heart valve
Infection of the heart (infective endocarditis)
A heart condition from birth (congenital heart disease)
Heart transplant
Hepatitis
Jaundice
Liver disease
Prosthetic Artificial Joint
Bleeding problem or bleeding disorder
Hospitalized for any illness or operations
Any conditions or therapies that could affect your immune system eg leukemia, AIDS, HIV infection, radiotherapy, chemotherapy
Diabetes
Cancer

	Yes	No
Have you been seeing a dentist regularly?
Do any of your teeth ache?
Have you ever been advised to take antibiotics before dental appointments?
Do your gums bleed when you brush?
Do you have any pain when you chew?
Do you feel that you have bad breath?
Have you ever been in a vehicle accident or experienced any trauma to your jaw?
Do you have any problems with your jaw joint (pain, sounds opening, locking, popping)

	Yes	No
Has your child seeing a dentist regularly?
Does any of his/her teeth ache?
Has your child ever been advised to take antibiotics before dental appointments?
Does your child's gums bleed when he/she brush?
Does your child have any pain while chewing?
Does your child feel that he/she has a bad breath?
Has your child ever been in a vehicle accident or experienced any trauma to his/her jaw?
Does your child has any problems with jaw joint (pain, sounds opening, locking, popping)

	Yes	No
Has your child seeing a dentist regularly?
Does any of his/her teeth ache?
Has your child ever been advised to take antibiotics before dental appointments?
Does your child's gums bleed when he/she brush?
Does your child have any pain while chewing?
Does your child feel that he/she has a bad breath?
Has your child ever been in a vehicle accident or experienced any trauma to his/her jaw?
Does your child has any problems with jaw joint (pain, sounds opening, locking, popping)

	Yes	No
Has your child seeing a dentist regularly?
Does any of his/her teeth ache?
Has your child ever been advised to take antibiotics before dental appointments?
Does your child's gums bleed when he/she brush?
Does your child have any pain while chewing?
Does your child feel that he/she has a bad breath?
Has your child ever been in a vehicle accident or experienced any trauma to his/her jaw?
Does your child has any problems with jaw joint (pain, sounds opening, locking, popping)

Patient Medical / Dental History Information

Responsible Party's Information

Existing Patient

Phone Number

Emergency Contact

Medical Update

Insurance

Primary Insurance

Secondary Insurance

Patient Consent For Electronic Insurance Claim Submission

New Patient

Telephone

Emergency Contact

Insurance Policy Information

Patient Consent For Electronic Insurance Claim Submission

Medical Health History

Dental History

Information Release

Family Member

Medical History

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Client Information and Consent Form for Whitening

Expectations

Aftercare and Follow-up

Release

Client Consent Form For Collection, Use And Disclosure Of Personal Information

	Yes	No
Do you have or have you had allergies or reactions to carbamide peroxide or glycerine?
Do you have existing tooth decay, periodontal disease or gingivitis?
Are you photosensitive or taking photosensitive medication?
Are you pregnant, suspected of being pregnant, or are you breastfeeding?
Are you under the age of 16?
Have you had oral surgery or extractions within the last 28 days?
Are you wearing a piercing or metal object in the oral cavity? (Please remove, as they may turn black)
Do you have a Latex or Rubber Product Allergy?
Are you under the care of a Physician for something specific at this time?