Laurelmanordental.net

PATIENT PERSONAL INFORMATION:
(PLEASE PRINT)
NAME:_________________________________________________________________________________________ ADDRESS:_______________________________________________________________________________________ CITY:__________________________________________________ STATE:_________________ ZIP:______________ HOME PHONE:________-_________-________ CELL PHONE: ________-_________-________
BIRTH DATE: _____/______/_______________ EMAIL:_______________________________________________ SOCIAL SECURITY NUMBER:_____________ - _______ - _________
PLEASE CHECK ONE: MARRIED □ SINGLE □ WIDOWED □ DIVORCED □ MINOR □ HOW DID YOU HEAR ABOUT OUR DENTAL OFFICE? ____________________________________________________________ DO YOU HAVE A FAMILY MEMBER WHO IS A PATIENT IN THIS OFFICE? YES □ NO □ THEIR NAME? :_______________________ EMERGENCY CONTACT INFORMATION:
NAME:_________________________________________________________________________________________ HOME PHONE:_______ -_________ -________OTHER PHONE: ______ _ -_________ -________RELATIONSHIP: _________
DENTAL INSURANCE INFORMATION:
INSURED’S NAME___________________________________________________________________________________ BIRTH DATE: _____/______/_______________ SOCIAL SECURITY NUMBER:_____________ - _______ - _________
RELATIONSHIP TO PATIENT: ____________________INSURED’S EMPLOYER: ________________________________ INSURANCE COMPANY: ____________________ GROUP/POLICY NUMBER: ________________________________ ADDRESS: _________________________________________________________________________________ CITY:__________________________________________________ STATE:_________________ ZIP:______________ Laurel Manor Dental - 1950 Laurel Manor Drive, Suite 180B - The Villages, FL 32162 352.430.1710
NAME:_________________________________________________________________________________________ DENTAL HISTORY:
PREVIOUS DENTIST’S NAME: _______________________________ PHONE NUMBER: ________-_________-________
DATE OF LAST EXAM: _____/______/_______ ARE YOU UNDER DENTAL CARE ELSEWHERE? YES □ NO □ HAVE YOU NOTICED:
HAVE YOU HAD ANY OF THE FOLLOWING:
SORES OR LUMPS IN/NEAR YOUR MOUTH YES □ NO □ A BITE PLATE OR MOUTHGUARD YES □ NO □ HAVE YOUR PARENTS EXPERIENCED GUM DISEASE OR TOOTH LOSS? MEDICAL HISTORY:
PHYSICIAN’S NAME: ________________________________________________ PHONE: _____-______-_______
HAVE YOU BEEN HOSPITALIZED FOR SURGICAL CARE OR SERIOUS ILLNESS WITHIN THE LAST FIVE (5) YEARS? YES □ NO □ DO YOU REQUIRE PRE-MEDICATION FOR DENTAL APPOINTMENTS? YES □ NO □

ARE YOU TAKING ANY MEDICATION(S) SUCH AS FOSAMAX OR ANY MEDICATION FOR OSTEOPOROSIS INCLUDING
VITAMINS OR NON-PRESCRIPTION MEDICINE?
PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING. PLEASE PROVIDE SPECIFIC DETAILS BELOW: YES □ NO □ DO YOU USE EXTRA PILLOWS TO SLEEP? YES □ NO □
ARE YOU AWARE OF HAVING HAD AN ADVERSE ALLERGIC REACTION TO ANY OF THE FOLLOWING?
LOCAL ANESTHETICS
YES □ NO □ ANTIBIOTICS (PENICILLIN, ETC.) YES □ NO □ PRESCRIPTION PAIN MEDICATION YES □ NO □ OTHER, PLEASE EXPLAIN: _________________________________________________________________________ Laurel Manor Dental - 1950 Laurel Manor Drive, Suite 180B - The Villages, FL 32162 352.430.1710

DO YOU HAVE OR HAVE YOU HAD ANY OF THE THE FOLLOWING:

HIGH BLOOD PRESSURE
YES □ NO □ CHEST PAINS/EASILY WINDED MITRAL VALVE PROLAPSE/HEART MURMER YES □ NO □ JOINT REPLACEMENT YES □ NO □ SEXUALLY TRANSMITTED DISEASES OTHER: ______________________ YES □ NO □
WOMEN ONLY:
ARE YOU TAKING ORAL CONTRACEPTIVES? YES □ NO □ HAVE YOU ENTERED MENOPAUSE? YES □ NO □
ARE YOU PREGNANT?
YES □ NO □ IF SO, WHAT TYPE?____________________________
OFFICE USE ONLY:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

AUTHORIZATION/RELEASE:
AS A CONDITION OF YOUR TREATMENT BY THIS OFFICE, FINANCIAL ARRANGEMENTS MUST BE MADE IN ADVANCE. THE PRACTICE DEPENDS UPON REIMBURSEMENT
FROM THE PATIENTS FOR THE COSTS INCURRED IN THEIR CARE AND 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 AT
THE TIME SERVICES ARE PERFORMED. PATIENTS WHO CARRY DENTAL INSURANCE UNDERSTAND THAT ALL DENTAL SERVICES ARE, AS A COURTESY, SUBMITTED
TO YOUR INSURANCE. 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 30-DAYS FROM THE DATE OF THE PATIENT
EXAMINATION. IN CONSIDERATION FOR THE PROFESSIONAL SERVICES RENDERED TO ME, OR AT MY REQUEST, BY THE DOCTOR, I AGREE TO PAY THE
REASONABLE VALUE OF SERVICES TO THE DOCTOR, OR HIS ASSIGNEE, AT THE TIME SERVICES ARE RENDERED. APPOINTMENTS CHANGED OR RESCHEDULED
ON SHORT NOTICE MAY BE SUBJECT TO A MISSED APPOINTMENT FEE. I FURTHER AGREE TO THE FOLLOWING; THAT THE REASONABLE VALUE OF SERVICES
SHALL BE BILLED UNLESS OBJECTED TO, BY ME, IN WRITING. I WILL NOT HOLD LAUREL MANOR DENTAL, MY DENTIST OR ANY MEMBER OF THE STAFF
RESPONSIBLE FOR ANY ERRORS OR OMISSIONS IN COMPLETING THIS FORM. I HAVE READ THE ABOVE CONDITIONS OF TREAMENT AND PAYMENT AND AGREE TO
THEIR CONTENT.
Laurel Manor Dental - 1950 Laurel Manor Drive, Suite 180B - The Villages, FL 32162 352.430.1710


______________________________________ _____/______/_______ _______________________
SIGNATURE OF PATIENT, PARENT OR GUARDIAN
RELATIONSHIP TO PATIENT
______________________________________ _____/______/_______ _______________________
SIGNATURE OF GUARANTOR OR PAYMENT/RESPONSIBLE PARTY
RELATIONSHIP TO PATIENT
Laurel Manor Dental - 1950 Laurel Manor Drive, Suite 180B - The Villages, FL 32162 352.430.1710

Source: http://www.laurelmanordental.net/docs/LMD_NewPT_InfoForms.pdf