Lake Quality Dental
Helene P. Ta DDS
1503 Buenos Aires Blvd Suite 125
The Villages FL 32159
Phone: (352) 753-5838
Fax: (352) 391-5837
PATIENT REGISTRATION
rst Name: _______ __________________
Last Name: __________________________ Middle Initial
First Name: _______________________ Last Name: ___________________________ Middle Initial: _______
Address: __________________________________ City: ___________________ State: _____ Zip: __________
Home Phone: _____________________ Work Phone: _________________ Employer: ____________________
Cellular: _____________________________________
Okay to Text appointment reminder.
E-Mail: ____________________________________ I would like to receive correspondence via e-mail: Y
N
Birth Date: ______/______/_________ SSN: _________-_______-________ Marital Status: _______________
Emergency Contact: _________________________ Phone: __________________ Relationship:_____________
DENTAL HISTORY:
What is the reason of your visit today? __________________________________________________________________
Are you experiencing pain or discomfort at this time?
Yes
Are you happy with the appearance of your teeth? Yes
Are you happy with the appearance of your smile? Yes
Are you able to eat and chew food satisfactorily?
Yes
Would you like to make your teeth Whiter?
Yes
Do you have headaches, earaches or neck pain?
Yes
Do you feel your breath offensive at times?
Yes
Do your teeth feel loose or separating?
Yes
Does food get caught between your teeth?
Yes
Difficulty opening or closing your mouth?
Yes
Difficulty in chewing on either side?
Yes
Are your teeth sensitive to Hot or Cold
Yes
Date of last dental visit:
Date of last cleaning:
No Would you like to keep your teeth?
Yes
No
No Do you clench or grind your teeth?
Yes
No
No Does your jaw click or pop?
Yes
No
No Do your gums bleed or feel tender?
Yes
No
No Have you ever had gum treatment?
Yes
No
No Have you lost or removed any teeth?
Yes
No
No Have they been replaced?
Yes
No
No
Fixed Bridge
Date placed: ________________
No
Removable Partial Date placed: ____________
No
Full Denture Date placed: _________________
No Are your teeth sensitive to sweets
Yes
No
Last full mouth x-rays:
Do you use dental floss?
How often are your hygiene visits:
3 months
No
4 months
Date started: ___________________________
6 months
1 year
Whom may we thank for referring you to our office? _________________________________________________
I give my consent to any advisable and necessary dental procedures, medication or anesthetic to be administered by the
attending dentist or by his/her supervised staff for diagnostic purposes or dental treatment.
These records may include study models, photographs, x-rays and blood studies.
I understand and acknowledge that I am financially responsible for the services provided for myself or the above named,
regardless of Insurance coverage.
I understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to
modify treatment, and its fee. To the best of my knowledge the information provided on this form is accurate.
Signature of Patient: ___________________________________
Date: ______________________
Signature of Doctor: ___________________________________
Date: ______________________
MEDICAL HISTORY
Although dental personnel primarily treat the area in around your mouth, your mouth is a part of your entire body. Health
problems that you may have, or medication that you may be taking, could have an important interrelationship with the
dentistry you will receive. Thank you for answering the following questions.
Patient name: _______________________________________________________ Birth Date: ______________________________
Primary Care Physician: ___________________________________Physician’s Phone:____________________________________
Preferred Pharmacy: _____________________________ Location: _______________________ Telephone: ___________________
Have you ever had to pre-medicate with antibiotics prior to dental treatment? Yes
No Type: ___________________________
Have you ever been hospitalized or had a major operation?
Yes
No If yes, please explain: ____________________________
Have you ever had a serious head or neck injury?
Yes
No If yes, please explain: ___________________________________
Are you on a special diet?
Yes
No If yes, please explain: _____________________________________________________
Do you use tobacco?
Yes
No If yes, how much?: ___________________ Do you use controlled substances?
Yes
No
WOMEN
Are you Pregnant/trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing?
Yes
No
Please be advised that antibiotics may reduce the effectiveness of oral contraceptives. Please consult a physician if antibiotics is
prescribed.
Signature of acknowledgement: ________________________________ Date: _____________
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Metal
Erythromycin
Sulfa drugs
Local Anesthetic
Tetracycline
Lidocaine
Latex
Other: If yes, please explain: __________________________
Please list all your prescription and over-the-counter medication you are taking. Please include herbal or natural supplements.
Please check all that applies:
___ AIDS/HIV Positive
___ Alzheimer’s Disease
___ Anaphylaxis
___ Anemia
___ Angina
___ Arthritis / Gout
___ Artificial Heart Valve
___ Artificial Joint
___ Asthma
___ Blood disease
___ Blood Transfusion
___ Breathing Problem
___ Bruise Easily
___ Cancer
___ Chemotherapy
___ Chest Pains
___ Cold Sores / Fever Blisters
___ Congenital Heart Disorder
___ High Cholesterol
___ Convulsions
___ Cortisone Medicine
___ Diabetes
___ Drug Addiction
___ Easily Winded
___ Emphysema
___ Epilepsy or Seizures
___ Excessive Thirst
___ Fainting spells / Dizziness
___ Frequent Cough
___ Frequent Diarrhea
___ Frequent Headaches
___ Genital Herpes
___ Glaucoma
___ Hay Fever
___ Heart Attack / Failure
___Heart Murmur
___ Heart Pace Maker
___ Heart Trouble / Disease
___ Hemophilia
___ Hepatitis A
___ Hepatitis B or C
___ Herpes
___ High Blood Pressure
___ Hives or Rash
___ Hypoglycemia
___ Irregular Heartbeat
___ Kidney Problems
___ Leukemia
___ Liver Disease
___ Low Blood Pressure
___ Lung Disease
___ Mitral Valve Prolapse
___ Pain in Jaw Joints
___ Parathyroid Disease
___ Psychiatric Care
___ Radiation Treatment
___ Recent Weight Loss
___ Renal Dialysis
___ Rheumatic Fever
___ Rheumatism
___ Scarlet Fever
___ Shingles
___ Sickle Cell Disease
___ Sinus Trouble
___ Spina Bifida
___ Stomach Intestinal
Disease
___ Stroke
___ Swelling of Limbs
___ Thyroid Disease
___ Tonsillitis
___ Tuberculosis
___ Tumors of Growths
___ Ulcers
___ Venereal Disease
___ Yellow Jaundice
All Payments are expected to pay in Cash, Check or Credit Card the day the service is rendered, unless
arrangements are made in advance.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect
information can be dangerous to my (or Patient’s) health. It is my responsibility to inform the dental office of any changes in my medical
status.
Signature: _______________________________________ Date: ________________________________
Lake Quality Dental
Helene P. Ta DDS
1503 Buenos Aires Blvd Suite 125
The Villages FL 32159
Phone: (352) 753-5838
Fax: (352) 391-5837
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
HIPPA
“You may refuse to sign this Acknowledgement”
I, _________________________________, have read and seen a copy of this office’s notice of privacy practice.
_______________________________
Print Name
______________________________
Signature
__________________
Date
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practice,
but acknowledgement could not be obtained because:
_____ Individual refuse to sign
_____ Communication barriers prohibited obtaining the acknowledgement
_____ An emergency situation prevented us from obtaining acknowledgement
_____ Other (Please specify) ____________________________________________________
BROKEN AND MISSED APPOINTMENT POLICY
Appointments are considered broken if not cancelled 24 hours prior to the scheduled time.
There is a maximum fee of $50.00 for any Broken Appointment.
This policy applies to any and all future appointments.
Our office has 24 hour telephone contact, either in person or message machine.
I have read and fully understand that I may be charged a fee for broken and missed appointments.
Signature: ______________________________________ Date: __________________
DENTAL INSURANCE INFORMATION ONLY:
We are only in-network providers for the PPO Plans with Delta Dental, United Healthcare and Principal.
We are not a provider for any other Insurance, as a courtesy we will file your Insurance claim and request
that the out of network reimbursement be remitted directly to you.
Insurance is only an estimate and not a guarantee of payment. Patient is fully responsible for total charges.
Please give your Insurance card and Picture ID to the receptionist to copy for your file.
Primary Insured: _____________________________ Relationship to Insured: __ Self __ Spouse __Other
Insures SSN: __________________ Insured Birth Date: ___________ Employer: _________________________
Insurance Company: ____________________________________ Group Number: ________________________
Insurance Address: _____________________________ City: ________________ State: _____ Zip: __________
Insurance Telephone Number: _________________________ Retired from: _____________________________
X-rays taken at no charge will be the property of Lake Quality Dental.
There will be a fee of $55.00 to transfer them to another dentist.
Lake Quality Dental
Helene P. Ta DDS
1503 Buenos Aires Blvd Suite 125
The Villages FL 32159
Phone: (352) 753-5838
Fax: (352) 391-5837
Musculoskeletal – Occlusal Signs Exam Form
Name: _______________________________ Today’s Date: _________________ Age _____
SYMPTOMS
THIS BOX ONLY
Headaches
TMJ Pain
TMJ noise
Limited opening
Ear congestion
Vertigo (dizziness)
Tinnitus (ringing in the ears)
Dysphagia (difficulty swallowing)
Loose teeth
Clenching / Bruxing (grinding)
Facial pain (nonspecific)
Tender, sensitive teeth (percussion)
Difficulty chewing
Cervical pain
Posture problems
Paresthesia of fingertips (tingling)
Thermal sensitivity (hot and cold)
Trigeminal neuralgia
Bell’s palsy
Nervousness / Insominia
SIGNS (EXTRA-ORAL)
Facial asymmetry bilaterally
Short lower third of the face
Chelitis
Abnormal lip posture
Deep mentalis crease
Dished-out or flat labial profile
Facial edema
Mandibular torticollis
Cervical torticollis
Forward head posture (lordosis)
Elongated lower face
(Steep mandibular angle)
Speech abnormalities
SIGNS (INTRA-ORAL)
Crowded lower anterior teeth
Wear of lower anterior
Lingual inclination of lower
anterior teeth
Lingual inclination of upper anterior teeth
(Div. II occlusion)
Bicuspid drop off
Depressed curve of spee
Lingually tipped lower posteriors
Narrow mandibular arch
Narrow maxillary arch
(High palatal vault)
Midline discrepancy
Malrelated dental arches
Tooth mobility
Flared upper anterior teeth
Facets
Cervical erosion (abfractions)
Locked upper buccal cusps
Fractured cusps (particularly CL I & II
Non-functional cusps)
Chipped anterior teeth
Loss of molars
Open interproximal contacts
Unexplained gingival inflammation
and hypertrophy
Crossbite
Anterior open bite
Anterior tongue thrust
Lateral tongue thrust
Scalloping of the lateral border of the
tongue