Confidential Patient Information
Name ____________________________________________
LAST
Date of Birth _____________
FIRST
Social Security # ___________________________
Driver’s License # ______________________
Home Address __________________________________________________________
City ___________________________ State _____ ZIP ________ Home # (
E-Mail Address___________________________________
)___________
Cell # ______________________
Marital Status____________________________________
Employed By ______________________________________________ Occupation ___________________
Work Address ______________________________________________ Work Phone (
) ____________
City ___________________________ State _______ ZIP __________
Name of Responsible Party_____________________________________
LAST
Relationship______________
FIRST
Work Address ______________________________________________ Work Phone (
City ___________________________
State _______ ZIP _________
Emergency Contact__________________________________
LAST
Phone (
) ____________
Relationship______________
FIRST
) _______________________
Date of Last Dental Visit __________________________ Reason for Last Dental Visit ________________
Name of Previous Dentist __________________________ Phone Number ___________________________
Physician's Name _________________________________ Phone Number ___________________________
How Did You Hear About Our Office: _______________________________________________________
Primary Dental Insurance
Co. Name _______________________________
Group/Policy #____________________________
Insured's Name ___________________________
Social Security # __________________________
Date of Birth ____________________________
Relationship to Insured _____________________
Secondary Dental Insurance
Co. Name _______________________________
Group/Policy # ___________________________
Insured's Name __________________________
Social Security#___________________________
Date of Birth_____________________________
Relationship to Insured ________________
I agree to be responsible for payment of all services rendered on my behalf or my dependents. Patients who carry dental
insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally
responsible for payment of all services. Our office will help prepare your insurance forms to assist in making collections from
insurance companies. However, we cannot render services on the assumption that our charges will be paid by an insurance
company.
Signature _____________________________
Date _________________
Confidential Medical History
Circle YES or NO
YES
NO
Are you having dental pain or discomfort at this time?
YES
NO
Do you have a history of Periodontal Disease?
Date of Last Treatment________
YES
NO
Have you been a patient in the hospital during the past two years?
YES
NO
Have you been under the care of a medical doctor during the past two years?
YES
NO
Have you taken any medicine or drugs during the past two years?
YES
NO
Have you ever had any excessive bleeding requiring special treatment?
Do you have or have had any of the following conditions?
Heart Failure
Heart Disease or Attack
Angina Pectoris
High Blood Pressure
Heart Murmur
Rheumatic Fever
Congenital Heart Lesions
Scarlet Fever
Artificial Heart Valve
Heart Pacemaker
Heart Surgery
Artificial Joint
Anemia
Stroke
Kidney Trouble
Ulcers
Emphysema
Cough
Tuberculosis (TB)
Asthma
Hay Fever
Sinus Trouble
Allergies or Hives
Diabetes
Thyroid Disease
X-ray or Cobalt Treatment
Chemotherapy (Cancer, Leukemia)
Arthritis
Rheumatism
Cortisone Medicine
Glaucoma
Pain in the Jaw Joints (TMJ)
Aids/ HIV
Hepatitis A/ Hepatitis B
Liver Disease
Yellow Jaundice
Blood Transfusions
Drug Addiction
Hemophilia
Venereal Disease (Syphilis, Gonorrhea)
Cold Sores
Genital Herpes
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervousness
Psychiatric Treatment
Sickle Cell Disease
Bruise Easily
Are you allergic to, or made sick by any of the following?
Penicillin
Aspirin
Valium
Latex Products
Erythromycin
Darvon
Novocaine
Other Drugs
Tetracycline
Codeine
Lidocaine
______________
Circle YES or NO
YES
NO
Has you Physician/Cardiologist ever told you that you need Antibiotics before dental treatment?
YES
NO
Do you experience shortness of breath, chest pain or feel very tired when walking up the stairs?
YES
NO
Do your ankles swell during the day?
YES
NO
Do you use more than 2 pillows to sleep?
YES
NO
Have you lost or gained more than 10 pounds in the past year?
YES
NO
Do you experience shortness of breath while sleeping?
YES
NO
Have you ever used any of the drugs known as fen-phen?
YES
NO
Have you been treated for cancer/tumor? Date & Type of Treatment ______________
YES
NO
Do you have any disease, condition, or problem not listed?
Women
YES
NO
Are you pregnant now, or do you anticipate becoming pregnant?
YES
NO
Are you practicing birth control?
To the best of my 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, without fail, inform the doctor at my next appointment.
Signature________________________________________________Date___________
____________________________________________________________________________________________
Changes in Health:___________________
Changes in Health:___________________
Changes in Health:___________________
Initial______________Date____________
Initial______________Date____________
Initial______________Date____________
SK
Silvia Kasparian, D.D.S
General and Cosmetic Dentistry
601 W. 5th Street, Suite 1110
Los Angeles, CA 90071
(213) 892-8172
Fax # (213) 892-8178
CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT
Patient Name:_____________________________
I hereby authorize the Doctor and/or staff members to take radiographs, study
models, photographs, or any other diagnostic aids deemed appropriate by the
doctor to make a thorough diagnosis of my dental needs. I also understand that
the use of anesthetic agents embodies a small risk.
I understand the responsibility for payment for Dental Services provided
in this office for my dependents or myself is mine, regardless of insurance
coverage. Such payments are due at the time services are rendered unless a
payment plan option is agreed upon. I further understand that there will be
absolutely no finance charges if the balance is paid on time; otherwise a 1.5%
finance charge (18% annually) will be added to any balance over 60 days. In the
event of default I (we) promise to pay legal interest on the indebtedness, together
with such collection of this note.
I am aware that if I am unable to keep my reserved appointment, I will notify the
office 48 hours in advance to avoid any cancellation fees that may apply. I understand
that a courtesy reminder may be made from the office to confirm my appointment date
and time.
I acknowledge receiving a copy of the Dental Material Fact Sheet as well as the
Notice of Privacy Practice Act.
Signature: ________________________________ Date: ________________