WELCOME

Thank you for filling out this form completely. Our goal is to help you achieve and maintain excellent dental health. The better we communicate, the better we can care for your needs. If you have any questions, we'll be glad to help! 

1. ABOUT YOU

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Sex

Marital Status

2. DENTAL INSURANCE

Do you have dental insurance? *
PRIMARY CARRIER
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Do you have secondary dental insurance? *
SECONDARY CARRIER
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GETTING TO KNOW YOU

How did you hear about us? (Check all that apply) *
 
Have you been out of the country in the past 3 weeks? *

PATIENT MEDICAL HISTORY

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PLEASE ANSWER YES OR NO TO THE FOLLOWING:
 YesNo
1. Are you under medical treatment now?
2. Have you been hospitalized for any surgical operation or serious illness within the last 5 years?
 YesNo
3. Are you taking any medication(s) including non-prescription medicine?
 YesNo
4. Do you have sleep apnea?
5. Do you chew tobacco or smoke?
6. Do you use controlled substances?
7. Do you have allergies?

Women Only:
 YesNo
8. Are you pregnant/think you may be pregnant?
9 Are you nursing?
10. Are you taking oral contraceptives?

Do you have, or have you had, any of the following?
 YesNo
Heart Condition/Heart Murmur
Rheumatic Fever
Epilepsy/Convulsions
Joint Replacement/Implants
AIDS or HIV infection
Sexually Transmitted Diseases
Arthritis
Stroke
Diabetes
Emphysema
Tuberculosis
Asthma
High Blood Pressure
Cancer/Leukemia
Cardiac Pacemaker
Kidney Disease
Stomach Trouble/Ulcers
Other

DENTAL HISTORY

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PLEASE ANSWER YES OR NO TO THE FOLLOWING:
 YesNo
1. Do your gums bleed while brushing or flossing?
2. Are your teeth sensitive to hot, cold or sweet liquids or foods?
3. Are any of your teeth painful?
4. Do you have any sores/lumps in/near your mouth?
5. Have you had any head, neck or jaw injuries?

6. Have you ever experienced any of the following:
 YesNo
Clicking
Pain (Joint, Ear, Side of Face)
Difficulty in opening/closing
Difficulty in chewing
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
 YesNo
7. Do you have frequent headaches?
8. Do you clench or grind your teeth?
9. Do you bite your lips or cheeks?
10. Have you had braces/invisalign?
11. Do you wear dentures or partials?

12. What, if anything, would you change about your smile?
(check all that apply) *
 
Authorization and Release
 
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of my dependents.

CONSENT FOR TREATMENT

  1. I hereby authorize Hudsonville Dental Associates and staff to take X-rays, study models, photos, and other diagnostic aids deemed appropriate by Dr. to make a thorough diagnosis of my dental needs.
  2. Upon such diagnosis, I authorize Hudsonville Dental Associates to perform all recommended treatment mutually agreed upon.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
  4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at time of service unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a finance charge of 12% APR will be added to my account.
  5. I have received a copy of this office’s HIPAA policy or have had the opportunity to request one.
6. I authorize Hudsonville Dental Associates to use my photographs and x-rays for research, marketing, education, or publication in professional journals. If you wish to decline the use of your photographs or x-rays for purposes other than diagnosis and treatment, please check here.
7. Your Privacy is important to us. If you would prefer we do not discuss your dental information with immediate family members, please check here.
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