North Beach Dental Care
9120 Chesapeake Ave. Ste. 301
North Beach, MD 20714
Phone: (443) 550-8115
www.NorthBeachDentist.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: _____________________________________________
Emergency Contact:
Relationship:
Phone:
Physician:
ZIP
Phone:
How did you hear about us? _______________________________________________
Yes

No
(PLEASE COMPLETE MEDICAL HISTORY ON BACK)
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.
2.
3.
4.
5.
6.
NO
NO
NO
NO
NO
NO
7.
8.
9.
10.
11.
12.
NO
NO
NO
NO
NO
NO
13. NO
14. NO
15. NO
16. NO
17. NO
18. NO
19.
20.
21.
22.
23.
24.
25.
NO
NO
NO
NO
NO
NO
NO
YES
Any Allergies? Please Specify_______________________________________.
YES
Blood pressure and/or heart problems?
YES
Rheumatic fever, heart murmur, mitral valve prolapse?
YES
Pacemaker, open heart surgery, prosthetic heart valve implant?
YES
Blood transfusions, organ transplant, artificial joint replacement?
YES
Tuberculosis, smoking or lung problems? Fever with night sweats and/or persistent,
productive cough?
YES
Hepatitis, jaundice or liver disease?
YES
Venereal disease, Herpes?
YES
Acquired Immune Deficiency Syndrome (AIDS) / HIV?
YES
IV drug use?
YES
Bleeding or clotting disorder?
YES
Diabetes, kidney, thyroid problems? Frequent urination; recent unexplained weight
change?
YES
Ulcers or stomach problems?
YES
Epilepsy or nervous disorder?
YES
Asthma, hay fever, sinusitis or other allergies (including latex)? Please specify if other:
____________________________________________
YES
Do any wounds heal slowly or present complications?
YES
Arthritis, Fibromyalgia or connective tissue disorder?
YES
Are you presently taking any medicine (prescription and/or OTC)? Please specify on
the back of this sheet for additional space if needed
____________________________________________________________.
YES
Are you presently under the care of a physician? Date of last physical exam __________
YES
Head, face or jaw trauma / injury?
YES
Have you ever been hospitalized?
YES
Cancer or tumors? Have you had x-ray treatments or chemotherapy?
YES
Body piercing or tattoos?
YES
WOMEN: Are you pregnant?
YES
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: ________________________________________
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.
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: ________________
North Beach Dental Care
9120 Chesapeake Ave. Ste. 301
North Beach, MD 20714
PH: (443) 550-8115
www.NorthBeachDentist.com