TISTAERT DENTAL
Title _________ Name __________________________________________DOB_______________
Address___________________________________________________________________________________
Phone: home ________________________________ work _________________________________________
Cell _______________________________________ single
married
widowed
divorced
partner
SS# _______________________________________ Email _________________________________________
Employer & Address ________________________________________________________________________
Insurance _________________________________________________________________ Secondary? ______
Spouse’s insurance? _______________________________________________________ SS# ______________
Emergency contact: _________________________________________________________________________
My Doctor _______________________________________________________________ Phone ___________
Allergies:___________________________________________________________________ Peanuts _______
Do you smoke? __________ Drink______________ Street drugs ______________ Pregnant? ______________
(WRITE yes or no)
Generally in good health? _____________ Ever take FenPhen or Redux _______________________________
Ever had reaction to anesthetic? _________ Describe_______________________________________________
Chronic med. Problems: Ms, Diabetes, etc. ______________________________________________________
Have or had hearth problems:
High blood pressure ________ thyroid________ medicine needed?_______________ Bleeding easily________
Stroke________ kidney_______ lungs (asthma, emphysema, etc) ________ cough________ candida ________
Mono________ liver(jaundice, hepatitis) ________ skin________ muscle/joint/bone________ epilepsy______
Mental________ fainting________ neurological________ eyes________ ears/hearing_______ sinus________
TMJ(pain, sounds, dislocated) __________ head injury__________ freq. headaches________ tumors________
Radiation/chemo________ infections(TB, AIDS/HIV, shingles, herpes, hepatitis, etc) ____________________
Venereal Diseases________________ Cold sores________ Artificial parts (joints, valves, pacemaker) _______
Add anything else, or explain _________________________________________________________________
Please initial________________ Date___________________
TISTAERT DENTAL
PRINT NAME______________________________________________
Until the patient is examined & dental needs know; it is not possible to know what financial arrangements will
be best. In this evaluations your will be receiving the best advice & assessment of Dr. Tistaert, who has many
years of personal experience as well as gleaned from his father’s and grandfather’s dental experience. So for
his expertise theses services are to be paid for at the time rendered. Afterwards we will agree upon treatment
and the estimate for those services; but as any work proceeds unexpected findings & adjustments can arise.
Fees for all emergency services are payable at the time of the visit. I give my consent for Dr. Tistaert, or his
associates, to give my insurance company any information required about my dental condition or treatment
needed to determine benefits for up to 5 years from this date. I understand I am responsible for dental services
regardless of my insurance. I understand & have had the change to ask any questions about this.
Date__________________ Patient____________________________________________________________
D.D.S. __________________________________
CURRENT MEDS: (i.e. blood thinners, aspirin, steroids, antihistamines, tranquilizers, diabetic drugs,
hearth/blood pressure, nitro, thyroid, herbal or natural remedies)
List ALL MEDS: ___________________________________________________________________________
List ALL ALLERGIES:______________________________________________________________________
List Surgeries:______________________________________________________________________________
Are you interested in cosmetic dentistry, whitening or other smile improvements?________________________
Any other dental questions/concerns? ___________________________________________________________
CONSENT FOR TREATMENT: I hereby grant permission to Dr. Tistaert or his associate for my dental care,
to administer such dental anesthetics as needed for dental work and to perform such operations or dental
procedures as deemed necessary or advisable in diagnosis & treatment of this myself, or my minor children.
FINANCIAL: fees to be paid in 30 days, older accounts will have a fee of 1.5% (1 ½ %) will be assessed each
month or 18% per year.
I have received the Dental Materials Face Sheet /law(initials)______________________ Date______________
Signed _________________________________________________________________ Date______________