Health History
Reason for visit: ______________________________________________________________________________________
_________________________________________________________________________________________________________
How long have you been feeling your symptoms? ________________________________________________
Do you use tobacco products? ______Yes ______No
If yes, how often do you use tobacco products? ___________________________________________________
Please list any medications you are currently taking.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Do you require premedication? ______Yes ______No
Have you ever had any complications following dental treatment? ___Yes ___No
If yes, please explain.
Are you now under the care of a physician? ___Yes ___No
If yes, please explain. ________________________________________________________________________________
Name of Physician ____________________________________________________ Phone _______________________
Do you have any other health problems that need further clarification? ___Yes ___No
If yes, please explain. ________________________________________________________________________________
Do you grind your teeth? ____Yes ____No
Would you like to whiten your teeth? ___Yes ___No
Do you currently or have you ever had any of the following? Check any that apply.
___ AIDS
___ Allergies (seasonal)
___ Allergies to medications
_____________________________
___ Allergies to sulfur / sulfa
drugs
___ Arthritis
___ Artificial Joins
___ Asthma
___ Blood Disease
___ Blood Transfusion
___ Cancer
___ Diabetes
___ Dizziness
___ Epilepsy
___ Excessive Bleeding
___ Fainting
___ Glaucoma
___ Growths
___ Hay Fever
___ Heart Disease
___ Heart Murmur
___ Radiation Treatment
___ Respiratory Problems
___ Rheumatic Fever
___ Stomach Problems
___ Stroke
___ Hepatitis
___ High Blood Pressure
___ Jaundice
___ Kidney Disease
___ Liver Disease
___ Lung Problems
___ Mental Disorders
___ Nervous Disorders
___ Pacemakers
___ Pregnancy:
Due Date: ____________
___ Thyroid Problems
___ Tuberculosis
___ Tumors
___ Ulcers
___ Venereal Disease
___ Latex Allergy
___ Other:
___________________________
___________________________
___________________________
___________________________
Patient Information
Patient Name:____________________________________________________________________________________________________
Last,
First
Middle
Guardian Name:_________________________________________________________________________________________________
Address:__________________________________________________________________________________________________________
Street
Apartment #
City
Social Security #:___________________________________
State
Zip Code
Date of Birth: __________________________________________
Gender: ___ Male ___ Female
Phone Home:____________________________Work:________________________Ext: ________ Cell:______________________
Preferred method of Confirmation: ____ Phone call ____ Text message ____ E-mail
Family Status: (Check all that apply) ___Married ___Single ___Widow
___Other: ______________________
E-Mail Address: _________________________________________________________________________________________________
Driver’s License #: ________________________________________________________________ State: _____________________
Insurance Information
Is patient insured? _______Yes ______No
Name of Insured: ____________________________________________________________________________________________________
Last,
First
Middle
Insured's Birth Date: _____________________________ ID #: ___________________________ Group #: _________________
Is Insured's Address same as above? _____Yes _____No
If not, what is address? _________________________________________________________________________________________
Insured's Employer Name: _____________________________________________________________________________________
Employer Address: _____________________________________________________________________________________________
Street
Apartment #
City
State
Zip Code
Patient's relationship to insured: ______________________________________________________________________________
Insurance Name: ________________________________________________________________________________________________
Insurance Address: _____________________________________________________________________________________________
Street
Apartment #
City
State
Zip Code
Emergency Contact
Name: ____________________________________________________________________________________________________________
Last
First
Middle
Relationship to patient: ________________________________________________________________________________________
Phone Home: ________________________________________________ Cell: _____________________________________________
How did you hear about us? __________________________________________________________________________________
Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in
advance. Our office depends upon reimbursement from our patients for the costs incurred during
their care, therefore financial responsibility on the part of each patient must be determined before
treatment. All emergency dental services, or any dental services performed without previous
financial arrangements, must be paid for in full at the time services are performed.
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 dental services.
This office will help prepare the patients insurance forms or assist in making collections from
insurance companies and will credit any such collections to the patient's account. However, this
dental office cannot render services on the assumption that our charges will be paid by an insurance
company.
I understand that the fee estimate listed for this dental care can only be extended for a period
of six months from the date of treatment plan.
I hereby authorize doctor or designated Dolby Family Dentistry staff to perform necessary
dental services, such as x-rays, study models, photographs, and other diagnostic aids deemed
appropriate by doctor to make a thorough diagnosis. I authorize the dentist and Dolby Family
Dentistry staff to perform all recommended treatment with my informed consent in connection with
my diagnosis and treatment plan. I agree to the use of anesthetics, sedatives and other medications
as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand
that I can ask for a complete recital of any possible complications.
I give consent to Dolby Family Dentistry staff and healthcare providers to use and disclose the
following information for the purposes of treatment, healthcare operations such as referrals,
treatment, audit and legal inquisitions: health history, contact, appointment, financial, diagnostic, and
treatment information.
I grant my permission to you or your assignee, to telephone me at home or at my work to
discuss matters related to this form. I have read the above conditions of treatment and payment and
agree to their content.
____________________________________________________
Patient
_______________________________
Date
____________________________________________________
Guardian
_______________________________
Date
Dolby Family Dentistry Appointment Policy
We strive to accommodate our patients by providing quality dental care in a timely manner. In
order to effectively do so, our office has implemented the following appointment policy. This policy
enables Dolby Family Dentistry to better utilize available appointments for our patients in need of dental
care.
Our staff will attempt to make confirmation calls three days prior to your appointment.
Confirmations are NOT validated unless we receive verbal confirmation. If our staff leaves a message via
voicemail or with someone other than the patient/guardian, it is the patient’s responsibility to call our office
to confirm their appointment.
As a courtesy to our office, cancellations or time adjustments must be made two business days
prior to your scheduled appointment. After two cancelled or no show appointments, we reserve the right to
schedule all future appointments on walk-in basis only. As a walk in patient, our office will make every
effort to deliver quality care as availability permits.
We realize there will be times when due to extraneous circumstances, you may be late for an
appointment. In such cases it may be necessary to shorten the length of the service, change the procedures
to be completed or reschedule for another date and time. We suggest that you arrive ten minutes prior to
your appointment to enjoy the full benefits of your service.
Thank you for your consideration,
Dolby Family
_____________________________________
Patient or Guardian/Date
___________
DFD Staff