Medical + Dental History Form

PATIENT INFORMATION

Patient Name Nombre *

First Last

Nick Name Prefiero ser llamado

Nick Name

Date of Birth Fecha de nacimiento *

mm-dd-yyyy

Gender Género *

Social Security Number (ADULTS)

Used to verify dental insurance benefits

Patient Mobile Celular (PARENT BELOW) *

Patient e-mail Correo electronico

example@example.com

Patient Address Direccion *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Patient School Escuela (MINORS)

Martial status Estado civil:

Spouse Name

Patient Employer (ADULTS)

Dentist (if no dentist, write NONE) *

FOR ADULT PATIENTS

Do you have dental insurance?

Yes No Not sure

Dental Insurance

Please text a copy of both sides of your card to us at 707-255-4400

Name of Subscriber

Insurance ID # or Subscriber #

Social Security Number

Used to verify insurance

PARENT #1 Information (MINORS)

Parent #1 Name

First Last

Parent #1 Mobile #

Parent #1 E-mail

example@example.com

Parent #1 Address (If different from patient)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent #1 Date of Birth

Date

Marital Status

Spouse Name

Parent #1 Employer

Does Parent #1 have Dental Insurance? *

Yes No Not sure

Parent #1 Dental Insurance

Please text a copy of both sides of your card to us at 707-255-4400

Insurance ID # or Subscriber #

Parent #1 Social Security Number

Used to verify insurance

PARENT #2 Information (MINORS)

Parent #2 Name

First Name Last Name

Parent #2 Mobile #

Parent #2 E-mail

example@example.com

Parent #2 Address (If different from patient)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent #2 Date of Birth

Date

Marital Status

Spouse Name

Parent #2 Employer

Does Parent #2 have Dental Insurance?

Yes No Not sure

Parent #2 Dental Insurance

Please text a copy of both sides of your card to us at 707-255-4400

Insurance ID # or Subscriber #

Parent #2 Social Security Number

Used to verify insurance

MEDICAL + DENTAL HISTORY

Last Dental Visit

Date

Any dental treatment you need to complete? (write NONE if up to date) *

What is your primary concern about your teeth?

What treatment are you interested in? CHECK ALL THAT APPLY *

Braces Invisalign Surgery Retainers Second opinion Baseline exam I want to hear what Dr. Cooke recommends Other

How did you hear about our office?

Anyone else treated in our office?

Check the conditions that apply to you: *

Asthma Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy NONE Other

List any medications you are taking and why (write NONE if no medications): *

List all allergies (write NONE if no allergies): *

Do you use tobacco of any form? *

Yes No

During the last year, have you taken bisphosphonates? *

Yes No

Have you had tonsils or adenoids removed? *

Yes No

Any history of jaw joint pain or dysfunction (TMJ/TMD? *

Yes No

Please describe any injury to teeth, mouth or jaws/chin (write NONE if no injury): *

Check all that apply: *

Clenching/Griding Lip biting/sucking Mouth breathing Nail biting Nursing/pacifier/bottle habits Speech problems Thumb/Finger sucking habit Tongue Thrust NONE OF THE ABOVE

Are you pregnant? *

Yes No Not Applicable

Our 12 second scan is less than a traditional film based panoramic radiograph when used with a lead apron and neck collar. CBCT offers our patients enhanced diagnostic value at a significantly reduced exposure. Simultaneously, CBCT scans can image the head and most of the neck. As dentists and orthodontists, we evaluate teeth, jaws, and surround supporting bone using CBCTs for those limited purposes. Our training and dental license does not provide for evaluating and diagnosing outside those areas. However, since CBCT imaging can cover a broader area, we want to offer you the opportunity to have your CBCT scan read by an oral radiologist, trained and licensed to evaluate and diagnose a broader area. CBCT may show evidence of disease of the cervical spine, skull, or arteries. We can have your CBCT scan read by an oral radiologist for a fee of $120.00. If you are interested in taking advantage of this service, please complete the applicable section below.

*

YES! I would like to have my CBCT scan read by an oral radiologist EVERY TIME and understand that I’m responsible for the additional cost of $120.00, which is separate from any orthodontic fees. I would like the results emailed to the address on file. YES! I would like to have my CBCT scan read by a radiologist ONLY if Dr. Cooke recommends it specifically. I understand that I’m responsible for the additional cost of $120.00, which is separate from any orthodontic fees. NO, I understand the risks and benefits of having my CBCT scan read and interpreted by an oral radiologist, however, I knowingly decline.

I authorize Dr. Cooke and/or her staff to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care. I authorize release of any information concerning my (or my child’s) health care for the purpose of evaluation and administering claims for insurance benefits. I authorize release of any information concerning my (or my child’s) health care for advice and treatment to interdisciplinary team members. I understand that where appropriate, credit bureau reports may be obtained. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment, and to the use of the same by the doctor. The information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.

I understand by checking YES constitutes a legal signature confirming that I acknowledge and agree to the above Consent *

YES

Today's' Date *

Patient or Legal Guardian Signature *

Clear