Churchton Dental Care
5770 Shadyside Rd, Ste. A
Churchton, MD 20733
443-203-4945
www.churchtondentalcare.com
DATE: _________________
Thank you for visiting our office! We want your visit to be pleasant and comfortable. Please help us prepare
to serve your treatment needs by completing this form and if you need assistance, don’t hesitate to ask.
Name
LAST
FIRST
MIDDLE INITIAL
NICKNAME
Address:
STREET
CITY
STATE
Employer:
Birthdate:
Phone:

Male

Female
Home
Work
May we contact you at work?
Mobile
Email Address: _____________________________________________
(Your email address will not be shared with 3rd parties)
Preferred Method of Contact:
Home
Work
Mobile
Emergency Contact:
Email
Relationship:
Phone:
Physician:
ZIP
Phone:
How did you hear about us? _______________________________________________
Yes

No
MEDICAL HISTORY
Certain illnesses and drugs may make it necessary to alter our treatment. Please assist us in your oral health care
by providing the following information. DO YOU HAVE A HISTORY OF:
1. NO
YES
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
17. NO
18. NO
19. NO
YES
YES
YES
20.
21.
22.
23.
24.
25.
26.
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
Allergy to penicillin, aspirin, local or general anesthetic or other drugs? Please specify if
Other
__________________________________________________________________
Blood pressure and/or heart problems?
Mitral valve prolapse, Rheumatic fever?
Pacemaker, open heart surgery, prosthetic heart valve implant? Stent?
Artificial joint replacement, blood transfusions, organ transplant?
Tuberculosis, smoking or lung problems? Persistent productive cough?
Hepatitis, jaundice or liver disease?
Venereal disease, Herpes?
Acquired Immune Deficiency Syndrome (AIDS) / HIV?
IV drug use?
Bleeding or clotting disorder?
Taking Blood Thinners: Aspirin, Plavix, Coumadin (Warfarin), Pradaxa, Aggrenox, Eliquis, Xarelto?
Diabetes, kidney, thyroid problems?
Ulcers or stomach problems?
Epilepsy or nervous disorder?
Asthma, hay fever, sinusitis or other allergies (including latex)? Please specify if other:
______________________________________________________________________
Do any wounds heal slowly or present complications?
Arthritis, Fibromyalgia or connective tissue disorder?
Are you presently taking any medicine (prescription and/or OTC)? Please specify or
request medications sheet from front desk for additional space if needed
_____________________________________________________________________________
Are you presently under the care of a physician? Date of last physical exam _______________
Head, face or jaw trauma / injury?
Have you ever been hospitalized?
Cancer or tumors? Have you had radiation therapy or chemotherapy?
History of taking Bisphosphonates (Fosamax, Zometa, Aredia, Actonel, Boniva, Reclast)?
WOMEN: Are you pregnant?
WOMEN: Are you taking birth control pills?
Is there any additional health information that we should know?
____________________________________________________________________________________________
____________________________________________________________________________________________
Reason for today’s visit:
____________________________________________________________________________________________
Date of last dental visit: ________________ For:________________________________________________
How do you feel about your smile? _______________________________________________________________
Is there anything you would like to change about your smile? __________________________________________
To the best of my knowledge, the above information is accurate. I will inform the doctor of any changes as soon
as they are known to me.
Dental Anesthesia
We strive to provide care that is above and beyond the Standard of Care. But even with all of our training and
technological advances, there are still risks associated with any dental procedure. One of those risks includes
paresthesia following dental anesthesia, which can be temporary or in very rare cases permanent.
Post Op Sensitivity
While we hope you never experience any discomfort after our care is over, it is important to realize that postoperative sensitivity is an occurrence following most dental procedures, including Fillings, Crowns, Scaling and
Root Planning and even tooth whitening.
Patient’s Agreement to Share Protected Health Information
Please list any individuals with whom we may share your medical and/or billing information. This means we can
verbally share medical and financial information as well as provide printed copies of items contained in your
medical record or billing statements. Any individual listed may also pick up information for you at the office, such
as approved prescriptions, work or school notes, etc.
Financial/Medical Information (3 Person Limit)
Name:
Relationship to patient:
_________________________
_____________________________
_________________________
_____________________________
_________________________
_____________________________
Patient’s Signature: ___________________________________________ Date: ___________________
FINANCIAL AGREEMENT
Welcome to our practice – we are delighted that you are trusting us with your oral healthcare
needs. In order to provide you with the best possible care, we pride ourselves in ensuring our
patients have a comfortable and pleasant visit.
In order to keep up with the latest technologies available in dentistry and avoid the expense of
patient billing, we are pleased to provide you with the choice of using Cash, Check, Visa,
MasterCard, Discover Card, American Express and Care Credit to cover the cost of treatment at
the time the services are rendered.
If you carry dental insurance, we are happy to send your insurance claim on your behalf. Should
the insurance company deny the claim for any reason, it is the responsibility of the patient to pay
in full for the services rendered.
NOTE: For extensive treatment (e.g. reconstruction, total restoration, etc.), we do offer several
payment options for your convenience.
I have read and understand that I am responsible for paying for treatment at the time of service
unless I have previously entered into a Payment Options Agreement. (If I am insured, I understand
insurance benefits are always an estimate, and not a guarantee of payment.)
BROKEN APPOINTMENT / SAME DAY CANCELATION FEE:
In order to best meet the needs of our patients, we reserve time on our schedule according to the
treatment planned for your appointment. Therefore, we ask that you contact our office at least 2
business days prior to your appointment if you are unable to make it. Appointments canceled
within 24 hours of the scheduled appointment are subject to a $50 fee.
Patient Name: __________________________________________________
Patient Signature: ____________________________________
Date: ________________
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