PATIENT INFORMATION FORM

Downloadable Version

PATIENT DETAILS
Patient Name*
First Last
Date of Birth*
Month
Day
Year
Home Phone*
Work Phone
Cell Phone
Email*
DL#
Place of Employment
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact
Name*
First Last
Phone*
Relationship to Patient
DENTAL HISTORY
When was your last Dental Check Up?
When were your last cavity detection x-rays taken?
Was it a full mouth dental x-ray?
Number of times a day you brush your teeth:
Do you floss?
Do your gums bleed when you brush?
Have you been diagnosed with periodontal disease?
Are your teeth sensitive to:
- Cold
- Hot
- Sweets
Do you clench or grind your teeth?
Do you wake up with jaw pain?
Does your jaw click?
Are there specific oral health issues that you would like to discuss at this visit?
Please select all that apply:
- Abnormal Bleeding
- Alcohol Abuse
- Allergies
- Arthritis
- Artificial Bones
- Artificial Heart Valve
- Asthma
- Blood Transfusion
- Bruise Easily
- Cancer-Chemotherapy
- Congenital Heart Defect
- Dental Implants
- Diabetes
- Difficulty Breathing
- Drug Abuse
- Epilepsy
- Fainting Spells
- Fever Blisters
- Frequent Headaches
- HIV & AIDS
- Heart Attack
- Heart Murmur
- Heart Surgery
- Hepatitis A
- Hepatitis B OR C
- High Blood Pressure
- Kidney Problems
- Liver Disease
- Low Blood Pressure
- Mitral Valve Prolapse
- Pace Maker
- Pain in Jaw Joints
- Rheumatic Fever
- Seizures
- Sinus Problems
- Stroke
- Taken Fen-Phen
- Taken Redux
- Thyroid Problems
- Tuberculosis
- Ulcers
- Venereal Disease
- Anemia
- Angina Pectoris
- Colitis
- Cosmetic Surgery
- Emphysema
- Glaucoma
- Hay Fever
- Hemophilia
- Night Sweats
- Pneumocystitis
- Psychiatric Problems
- Smoke or use of Tobacco
- Pregnant/Trimester
- Bisphosphonates
- Joint Replacement
- Sleep Apnea
- Wear a CPAP
Allergies:
- Aspirin
- Codeine
- Dental Anesthetics
- Jewelry
- Metals
- Latex
- Penicillin
- Keflex
- Sulfa Drugs
- Tetracycline
- Erythromycin
- Clindamycin
Weeks:
How long ago?
Other conditions not listed:
Are you under the care of a Physician?
Physician Name:
For what condition(s)?
Are you taking any medications? (Include over the counter medications)
List:
Preferred Pharmacy:
Phone
Are you taking Birth Control Pills?
Have you in the past had to pre-medicate with antibiotics before dental visits?
How did you hear about our office?
Whom may we thank for referring you to our office:
POLICY FOR CANCELING AND CONFIRMING APPOINTMENTS

It is the practice in our office to provide every patient and the treatment they need the special attention deserved. Our office does not overbook patient appointments; however, we will DOUBLE BOOK any unconfirmed appointment. So that we can accommodate all our patients' needs, we ask that you provide us 24 hours notification if you are unable to keep a scheduled appointment. The office staff will attempt to contact you to remind you of your appointment. If we are unable to reach you one business day before your appointment by 2PM on a Monday - Thursday or 11AM on a Friday, it is considered an unconfirmed appointment and will be taken off our schedule. Please provide us the phone numbers where we can best reach you or leave a message during daytime hours.
RESPONSIBLE and/or INSURANCE PARTY
Employee Name
First Last
SS#
Date of Birth
Month
Day
Year
Relationship to Patient
Employer
Insurance Company
ID Number
Group Number
For patients under 18 and under we need information of a Parent or Legal Guardian, if not listed above
Name of Parent/Guardian
First Last
Date of Birth
Month
Day
Year
Relationship to Patient
SS#
Phone
In consideration of professional services performed by James M. Seaver, D.D.S. and Tyler L. Pittman, D.D.S, P.C., the undersigned hereby accepts total and absolute responsibility for all costs incurred as a result of such treatment and services not covered by any acceptable insurance. In the event of default in the payment of any amount due, after thirty days, the undersigned agrees to pay a services charge in an amount not exceeding 1.8% per month on this account. Further in the event this account is referred to an attorney or collection agency, the undersigned agrees to pay reasonable attorney fees, but in no case less than $100.00, or collections fees and court costs as permitted by laws governing these transactions. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic and therapeutic procedures (such as X-rays + fluoride treatment) as may be necessary for proper dental diagnosis and care. The information on this page and the medical history are correct to the best of my knowledge. I have read and understand the above stated policies and completed this questionnaire accurately and completely.
SIGNATURE OF RESPONSIBLE PARTY
Name*
Date*
Month
Day
Year

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PATIENT INFORMATION FORM

PATIENT DETAILS

Emergency Contact

DENTAL HISTORY

POLICY FOR CANCELING AND CONFIRMING APPOINTMENTS

RESPONSIBLE and/or INSURANCE PARTY

For patients under 18 and under we need information of a Parent or Legal Guardian, if not listed above

SIGNATURE OF RESPONSIBLE PARTY