| Name(last) | Smoke | ||||
| First/MI | Pack/day, since age of | ||||
| Born(m/d/yr) | Last cleaning yr | ||||
| SSN | Brush: once or twice a day | ||||
| Address | Floss: daily, rare, never | ||||
| Reason for visit today | |||||
| Name of Ex-dentist | |||||
| Home phone | Reason for Leaving | ||||
| Work | Medical Health | ||||
| Cell | Name of Physician | ||||
| Employer | Phone | ||||
| Dental Insurance | Last Exam yr | ||||
| Subscriber | Do you have | Y | N | ||
| SSN | High blood pressure | ||||
| In Case of Emergency | Congestive heart failure | ||||
| Contact | Do you take med such as | ||||
| Phone | Plavix, Coumadin, Osteoporosis | ||||
| How to know us Insurance, Ad, | Antibiotic before surgery | ||||
| Friend, Family, Sign, Yellow Page | Heart murmur, valve problem | ||||
| Dental Health | Y | N | Easy bruising, abnormal bleeding | ||
| Swollen, bleeding Gums | Sinus problem, Asthma | ||||
| Bad breath | Liver: Hepatitis, jaundice | ||||
| Toothache at night or on | HIV+/AIDS | ||||
| Hot, cold, sweet, chewing | Hospitalized in past 5 yrs | ||||
| Jaw joint click, pain | Allergy to med or Latex | ||||
| Grind or Clench | Disease not listed above | ||||
| Easy Gagging | List meds you take or took last year | ||||
I agree
to receive diagnosis and treatment
I
understand that the practice of dentistry is not an exact science and that
NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the outcome
and/or result of any procedures
You
have my permission to ask respective health care provider or agency to
release information to you. I
will notify the doctor of any change in my insurance,
health or medication
I
know that payment is due when service is rendered and that $35 may be
charged for appointment canceled <24 hours or no show, or returned check
I have read Financial Agreement and Notice of Privacy Practices
I authorize Dr. Wei to use my document to request payment from insurance, OR
I would like to pay in full and obtain reimbursement from insurance myself (choose one of the last two above)
Patient/Guardian Signature