New Patient Forms | Alan Mauldin, DDS

Online Patient Information Form

PATIENT INFORMATION

Date

Patient Last Name

First Name

Middle Initial

Street Address

City

State

Zip

Patient Email

Sex

Patient Employer/School

Age

Date of Birth

Occupation

Employer/School Address

Employer/School Phone

How many years?

Spouse's Name

Date of Birth

SS#

Spouse's Employer

Home Phone

Work Phone

Cell Phone

Spouse's Work Phone

Best time and place to reach you

EMERGENCY CONTACT

Name

Home Phone

Relationship

Work Phone

DENTAL INSURANCE

Who is responsible for this account?

Insurance Company

Relationship to Patient

Group Number

Is patient covered by additional insurance? Required

Yes

Subscriber's Name

Date of Birth

SS#

Relationship to Patient

Insurance Company

Group Number

ASSIGNMENT & RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Insurance Company

and

assign directly to Dr.

Doctor's Name

all insurance benefits, if any, otherwise payable to me

for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the

above-named Insurance Company(ees) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Name of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

DENTAL & MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.

Reason for today's visit

Former Dentist

Date of last dental visit

City/State

Date of last dental X-rays

PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:

Bad breath Required

YES

Bleeding gums Required

YES

Blisters on lips or mouth Required

YES

Cigarette, pipe or cigar smoking Required

YES

Clicking or popping jaw Required

YES

Dry mouth Required

YES

Burning sensation on tongue Required

YES

Fingernail biting Required

YES

Chew on one side of mouth Required

YES

Food collection between teeth Required

YES

Foreign objects Required

YES

Lip or cheek biting Required

YES

Orthodontic treatment Required

YES

Sensitivity to heat Required

YES

Grinding teeth Required

YES

Loose teeth or broken fillings Required

YES

Pain around ear Required

YES

Sensitivity to sweets Required

YES

How often do you floss?

Gums swollen or tender Required

YES

Mouth breathing Required

YES

Periodontal treatment Required

YES

Sensitivity when biting Required

YES

Jaw pain or tiredness Required

YES

Mouth pain, brushing Required

YES

Sensitivity to cold Required

YES

Sores or growths in your mouth Required

YES

How often do you brush?

Women, are you:

Pregnant/trying

Nursing

Taking oral contraceptives

If other, please specify:

Are you under a physician's care now? Required

YES

If yes:

Are you taking any pills, medication or drugs? Required

YES

If yes:

Are you on a special diet? Required

YES

Have you ever been hospitilized or had a major operation? Required

YES

If yes:

Do you take, or have taken, Phen-Fen or Redux? Required

YES

If yes:

Have you ever had a serious head or neck injury? Required

YES

If yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates? Required

YES

If yes:

Do you use tobacco? Required

YES

Do you use controlled substances? Required

YES

If yes:

DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?

AIDS/HIV Positive Required

YES

Alzheimer's Disease Required

YES

Anphylaxis Required

YES

Anemia Required

YES

Angina Required

YES

Arthritis/Gout Required

YES

Artificial Heart Valve Required

YES

Artificial Joint Required

YES

Asthma Required

YES

Blood Pressure Required

YES

Blood Transfusion Required

YES

Breathing Problems Required

YES

Bruise Easily Required

YES

Cancer Required

YES

Chemotherapy Required

YES

Chest Pains Required

YES

Cold Sores/Fever Blisters Required

YES

Congenital Heart Disorder Required

YES

Convulsions Required

YES

Cortisone Medicine Required

YES

Diabetes Required

YES

Drug Addiction Required

YES

Easily Winded Required

YES

Emphysema Required

YES

Epilepsy or Seizures Required

YES

Excessive Bleeding Required

YES

Excessive Thirst Required

YES

Fainting Spells/Dizziness Required

YES

Frequent Cough Required

YES

Frequent Diarrhea Required

YES

Frequent Headaches Required

YES

Genital Herpes Required

YES

Glaucoma Required

YES

Hay Fever Required

YES

Heart Attack/Failure Required

YES

Heart Murmur Required

YES

Heart Pacemaker Required

YES

Heart Trouble/Disease Required

YES

Hemophilia Required

YES

Hepatitis A Required

YES

Hepatitis B or C Required

YES

Herpes Required

YES

High Blood Pressure Required

YES

High Cholesterol Required

YES

Hives or Rash Required

YES

Hypoglycemia Required

YES

Irregular Heartbeat Required

YES

Kidney Problems Required

YES

Leukemia Required

YES

Liver Disease Required

YES

Low Blood Pressure Required

YES

Lung Disease Required

YES

Mitral Valve Prolapse Required

YES

Osteoporosis Required

YES

Pain in Jaw Joints Required

YES

Parathyroid Disease Required

YES

Psychiatric Care Required

YES

Radiation Treatments Required

YES

Recent Weight Loss Required

YES

Renal Dialysis Required

YES

Rheumatic Fever Required

YES

Rheumatism Required

YES

Scarlet Fever Required

YES

Shingles Required

YES

Sickle Cell Disease Required

YES

Sinus Trouble Required

YES

Spina Bifida Required

YES

Stomach/Intestinal Disease Required

YES

Stroke Required

YES

Swelling of Limbs Required

YES

Thyroid Disease Required

YES

Tonsillits Required

YES

Tuberculosis Required

YES

Tumors or Growths Required

YES

Ulcers Required

YES

Venereal Disease Required

YES

Yellow Jaundice Required

YES

Have you ever had any serious illness not listed above? Required

YES

If yes:

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, Guardian or Personal Representative

Date

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM

I understand, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health/dental information. I understand this information can and will be used to:

Conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in my treatment directly and/or indirectly.
Conduct normal healthcare operations, such as physician certifications and assessments.
Obtain payment from third party payers, such as insurance companies.
Confirm and leave messages at phone numbers provided to this office.

I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at anytime to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or dental care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name

Relationship to Patient

Additional family members given access

Signature

Date

Thanks for submitting!

Online Patient Information Form

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