Mount Vernon Dental Smiles
8101 Hinson Farm Road
Suite 216
Alexandria, VA 22306
703-360-6455
admin@mountvernonsmiles.com
703-360-6455
admin@mountvernonsmiles.com
PATIENT INFORMATION
Welcome to our office! To assist us in serving you, please complete the following confidential form.
The information provided is important to your dental health.
Patient's name ____________________________________________ Preferred name __________________ Birth date___________
If minor, Parent’s name(s)_____________________________________ Home phone _____________________________________
Cell Phone_____________________ Work phone ___________________Email address ___________________________________
Mailing address _________________________________________ City ____________________State ________ Zip ___________
Employer ____________________________________ Occupation ___________________________________________________
Spouse's name ________________________________ Spouse's employer _________________________________
 Unmarried
Whom may we thank for referring you to our office? ____________________________________________________  Phonebook
BILLING, CREDIT, AND INSURANCE INFORMATION:
 Not covered by dental insurance
Your Social Security number: _____________________ Dental Insurance Co._________________ Group number____________
Covered by spouse’s insurance?
 Yes
 No
Spouse's dental insurance company _______________________ Group number __________________
Spouse's birthday ______________________ Social Security number ___________________________
MEDICAL HEALTH HISTORY
Do you have or have you had any of the following?
Are you allergic to, or have you reacted adversely to any of the
(Please check any that apply)
following?
 Pre-med/Amox.
 Latex materials
 Cancer or tumor
 Penicillin or other antibiotics
 Heart ailment or angina
 Local anesthetics ("Novocain")
 Heart murmur, mitral valve prolapse, heart defect
 Codeine or other narcotics
 Rheumatic fever or rheumatic heart disease
 Sulfa drugs
 Artificial joint or valve
 Barbiturates, sedatives, or sleeping pills
 High or low blood pressure
 Aspirin
 Pacemaker
 Other:______________________________________
 Tuberculosis or other lung problems
 Kidney disease
Are you taking any of the following?
 Hepatitis or other liver disease
 Aspirin
 Blood transfusion
 Anticoagulants (blood thinners)
 Diabetes
 Antibiotics or sulfa drugs
 Neurologic condition
 High blood pressure medicine
 Epilepsy, seizures, or fainting spells
 Antidepressants or tranquilizers
 Emotional condition
 Insulin, Orinase, or other diabetes drug
 Arthritis
 Nitroglycerin
 Herpes or cold sores
 Cortisone or other steroids
 AIDS or HIV positive
 Osteoporosis (bone density) medicine
 Migraine headaches or frequent headaches
 Other:______________________________________
 Anemia or blood disorders
______________________________________
 Abnormal bleeding after extractions, surgery, or trauma
______________________________________
 Hayfever or sinus trouble
 Allergies or hives
Women:
 Asthma
Are you pregnant? __________________
 Dry mouth
Expected delivery date: _____________
 Fainting
 Snoring/Sleep Apnea
 Taking hormones or contraceptive
 Stroke
 Other __________________________________________
_______________________________________________
Do you smoke or use chewing tobacco?
Would you consider yourself to be in fairly good health?
Within the past year, have there been any changes in your general health?
What is the approximate date of your last medical exam?
_________________________________________________________
Your Primary Care Physician’s name, address, & phone number
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please mark any of the following that apply to you:
Have you ever had complications follwing dental treatment?
Are you currently under the care of a physician due to a specific condition?
Have you ever been hospitalized withing the last 5 years due to surgery or illness?
Are your currently taking any perscription or non-perscription medication?
Do you require the use of corrective lenses (contacts or glasses)?
Do you have any other conditions, diseases, etc, not listed previsouly that we should be aware of?
If any of the previous questions are marked, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of patient (or parent) _______________________________________
Date __________________
What is the reason for your dental visit today?
_________________________________________________________________________________________
__________________________________________________________________________________________
When was your last visit to the dentist (if a different office)?
__________________________________________________________________________________________
What was done on your last dental visit (if a different office)?
__________________________________________________________________________________________
Prior Dentist name, address, and phone number:
__________________________________________________________________________________________
__________________________________________________________________________________________
How frequently do you brush your teeth?
How frequently do you floss your teeth?
Please mark any of the following that apply to you:
Do your gums bleed when you brush or floss?
Do your teeth experience sensitivity to cold or hot temperatures?
Are any of your teeth currently causing you pain?
Do you grind or clench your teeth (either consciously or during sleep)?
Are any of your teeth loose, or are you concerned about any teeth loosening?
Do your currently have any dental implants, dentures, or partials?
Are you currently happy with your smile? Is there anything you would change about your teeth or oral health?
If any of the previous questions are marked, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Authorization
I herby certify that I have read and understand the previous information and that it is accurate and true to the
best of my knowledge.
I acknowledge that providing incorrect and or inaccurate information has the potential of being hazardous to my
health. I authorize the diagnosis of my health by means of radiographs, study models, photographs, and other
diagnostic aids deemed appropriate.
I authorize the dentist to release any information including the diagnosis and records of treatment or
examination for myself and my dependent(s) to third-part insurance carriers, payors, and or healthcare
practitioners. I authorize the payment form my insurance carrior to submit payment directly ot the dentist or
dental practice to be applied directly to any outstanding balance.
I understand that I am financially responsible for any outstanding balance for services provided that are not fully
covered by insurance, and I will be billed for this remaining balance.
Appointments and Cancellations
When we make your appointment, we are reserving a room for your particular needs. We ask that if you must
change an appointment, please give us at least 48 hours notice. This courtesy makes it possible to give your
reserved room to another patient who would like it. There will be a $50.00 charge for cancelling hygiene
appointments and $37.50 charge per ½ hour for cancelling a Doctor’s appointment when you do not provide at
least 24 hour notice. Repeated cancellations or missed appointments will result in loss of future appointment
privileges. We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your
records are prepared, and special instruments are readied for your visit.
Signature of patient, parent, or guardian:
Signature: ____________________________________________
Date: ______________________
Relationship to patient: ___________________________________________________________